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September 20, 2014 / 25 Elul, 5774
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Diabetes – The Silent Killer


The worldwide diabetes epidemic and its related precursor, obesity, are the fastest growing public health menaces of the 21st century.

Diabetes mellitus is a chronic condition resulting from the body’s inability to properly control blood sugar (glucose). Normally, the body controls the glucose level with a hormone produced in the pancreas called insulin. Those who have diabetes have either lost the ability to produce enough insulin, or the cells in their body no longer respond properly to the insulin that is being produced.

More than 90% of diabetes cases in the US today are Type 2, and less than 10% are Type1.

Diabetes was well known to the ancients, but the current epidemic of Type 2 diabetes is a phenomenon of modern living. It is largely the result of eating an unhealthy diet combined with a sedentary lifestyle. As a result, diabetes is nearly four times as common today as all types of cancer combined, and it causes more deaths each year than breast and prostate cancer combined.

More than 25 million Americans already have diabetes, and more than double that number have blood sugar numbers high enough to classify them as suffering from pre-diabetes. That means that they are likely to develop the full blown Type 2 diabetes in the near future if they do not make the necessary changes in their diet and lifestyles to prevent it.

Type 1 and Type 2 diabetes have many of the same symptoms and potentially deadly consequences, but different causes. Type 1 diabetes is also known as “juvenile diabetes” because in most cases it appears in childhood, in contrast with Type 2, which used to occur only in adults, which is why it was formerly known as adult-onset diabetes.

Type 1 is an autoimmune disease, like Rheumatoid Arthritis and Lupus, in which something triggers the body’s own immune system to attack the insulin-producing beta cells in the part of the pancreas known as the islets of Langerhans.

Type 1 cannot be cured, but it can be effectively managed. Proper insulin therapy, combined with regular monitoring of blood sugar levels, can allow people with Type 1 diabetes to lead a normal and healthy life.

One of the most insidious aspects of Type 2 diabetes is that by the time people are diagnosed with it, they may have already developed a serious long term complication of the condition. Type 2 doubles the risk of cardiovascular disease, which ultimately kills 52% of people with diabetes. People diagnosed with Type 2 also have double the risk of suffering a stroke within 5 years. Almost one in three will eventually develop kidney disease, and diabetes is one of the leading causes of adult blindness.

Diabetes is also associated with circulation problems in the lower extremities. This can result in the slow healing or infection of wounds on the feet and legs. This is further complicated by the fact that high blood sugar due to diabetes can cause damage to the nerves that sense pain. This means that diabetes patients may not realize that they have a wound on their leg or foot until after it has become dangerously infected. This can ultimately lead to the need for amputation.

Type 2 diabetes is also a condition related to aging. Approximately 20% of the population over 60 have the condition, and an equal number have its precursor. It is no longer called “juvenile” diabetes because of the shocking relatively recent result of the obesity epidemic, the discovery of Type 2 diabetes, for the first time, in grossly overweight teenagers and young adults.

Type 2 is typically treated with oral medications such as metformin, and it, too, requires the monitoring of blood sugar levels. The good news is that pre-diabetes or mild cases of Type 2 can also be controlled through appropriate changes in diet and lifestyle and weight loss. These are more effective, but require a lot more work and discipline, than taking pills. In fact, there is evidence that Type 2 diabetes can actually be reversed, in at least some cases, with sufficiently aggressive and strictly observed diet and lifestyle changes and weight loss.

There are other types of diabetes, the most common being gestational diabetes, a temporary condition which affects 2-5% of pregnant women and generally subsides after the baby is born. The symptoms are similar to those of Type 2 diabetes, and women who have had gestational diabetes are at higher risk of developing Type 2 diabetes later in life.

Women with gestational diabetes must be treated and closely monitored, because of the potential danger from the diabetes to the health of both the mother and the fetus. Gestational diabetes in the mother puts the baby at greater risk for high birth weight, cardiac and central nervous system problems, respiratory distress and skeletal muscle malformations. The damage done to blood vessels could impair the function of the placenta, causing fetal distress requiring early delivery through the induction of labor or cesarean section.

Metabolic syndrome is the name for an increasingly common cluster of symptoms exhibited together in the same patient which are likely due to common factors. People with metabolic syndrome are at increased risk for coronary artery disease, stroke, and type 2 diabetes. The greatest risk factor for metabolic syndrome is obesity in which most of the extra weight, in the form of fat, is found in the chest and abdomen, giving the body an “apple” shape. It is also commonly associated with the phenomenon of insulin resistance, in which the body is unable to use insulin properly to control blood sugar and fat levels, leading to pre-diabetes. Other risk factors for metabolic syndrome include age, lack of exercise, and genetic factors.

While not yet proven, scientists have a theory about how excess fat, especially in the abdomen, leads to Type 2 diabetes. Dr. Naveed Sattar, professor of metabolic medicine at the University of Glasgow, in Scotland, believes that if too much fat is stored in the abdomen, it can interfere with the way the pancreas produces insulin, and the way that the liver uses it to control blood sugar and fat levels in the body.

Glucose is one of the main fuels for the cells of the body. It is released into the bloodstream by the digestion of the carbohydrates in our food. Insulin is used by the body to help maintain a constant level of glucose in the bloodstream by stimulating the liver and muscle cells to store excess glucose in the form of glycogen. When there is too much glycogen to be conveniently stored, the body turns it into fat which is stored in fat cells.

According to Dr. Sattar, Type 2 diabetes may be the result of the body being unable “to make and store fat safely. Some people can store fat subcutaneously (under the skin). With others, it goes straight to the liver and pancreas. That’s the classic big waist, pot belly shape; the fat isn’t distributed around the body.” According to the theory, at some point that excess fat interferes with the proper functioning of the liver and pancreas.

The classic symptoms of uncontrolled diabetes include increased frequency of urination accompanied by increased thirst, and increased hunger. The symptoms develop more rapidly (over a few weeks or months) in type 1 diabetes while in type 2 diabetes they usually develop much more gradually and may therefore be more difficult to notice.

Another symptom of uncontrolled diabetes is blurred vision, because of changes caused by high blood glucose levels in the shape of the lens of the eye.

Many of the long term complications from diabetes are the result of its accumulated damage to blood vessels throughout the body, including the coronary arteries, the veins in the legs, and the tiny blood vessels found in the retina of the eye and in the kidneys.

How does one get diabetes? Scientists are not sure, but for Type 1, heredity plays only a minor role. Less than 10% of people with Type 1 have a family history of the condition. Scientists believe that even those with a genetic predisposition still must be exposed to an unknown triggering mechanism for the autoimmune reaction which destroys the body’s ability to produce insulin.

Type 2 has a much stronger hereditary component, particularly when both parents have the condition. But even those who have those genetic factors can lower their risk by maintaining a proper weight and exercising regularly.

While there is no cure for Type 1 diabetes, there has been encouraging progress in its treatment. A new generation of miniaturized insulin infusion pumps is being developed which includes a continuous blood glucose monitoring system. Once perfected, the system would be implanted under the skin to function like an artificial pancreas.

There are also ongoing experiments with transplants of pancreatic cells or stem cells to start producing insulin in the body again. But for now, most people with the condition still must rely on daily insulin injections.

However, for people with Type 2 diabetes, there are viable alternatives to lifelong dependence on medications. In a recent study, more than 70% of subjects with Type 2 who underwent bariatric (gastric bypass or lap band) surgery, and who lost more than 30 pounds of body weight, appeared to be free of the condition. Similar benefits can be obtained by following a very low-carbohydrate diet, combined with regular exercise, which is intended not only to eliminate body weight, but also to slash the amount of fat around the liver and pancreas.

According to Dr. Joel Goodman, the head of the Department of Endocrinology and Metabolism at Brookdale University Hospital and Medical Center, in Brooklyn, NY, a low-carb diet is most appropriate for people treating their Type 2 diabetes.

Jews appreciate good food, and perversely, diabetes actually increases the body’s cravings for food, making it more difficult to curb one’s appetite. Yet today, religious Jews with diabetes can, within certain limitations, eat the traditional foods they love on Shabbos, Yom Tov and even Passover without endangering their health. Readily available resources provide diabetes-safe recipes for Jewish delicacies, halachic guidance, support and counseling.

The obesity epidemic and the climbing diabetes statistics amount to a nationwide public health emergency. Yet, thanks to modern medical science, we have a much better understanding of this silent killer. Jews with diabetes, in particular, are no longer faced with the dilemma of being forced to choose between following our traditions and beliefs or protecting our health.

Resources: 1. Friends With Diabetes (www.friendswithdiabetes.org) A Rockland County-based support group for religious Jews with diabetes. Distributes diabetes-safe recipes, sponsors meetings (separated by gender and age), and presentations by renowned rabbonim. Publications, edited by Rabbi Hirsch Meisels, in English, Hebrew and Yiddish, address halachic, social and health challenges facing frum Jews living with diabetes.

2. Jewish Diabetes Association (http://jewishdiabetes.com) An organization devoted to diabetes education and advocacy offering its website, magazine and contact persons in both Hebrew and English.

3. Living With Diabetes (www.mendosa.com) Informational website

4. American Diabetes Organization (http://www.diabetes.org)
An organization dedicated to preventing and curing diabetes and improving the lives of all people affected by the disease.

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