Curing Diabetes

The primary role of fat in diet is that of an energy source, either for immediate needs or for storage in adipose tissue for later use. However, excessive fat intake causes elevated levels of blood lipids, which consist of cholesterol, lipoproteins, and triglycerides. Lipoproteins are classified as low-density lipoproteins (LDLs), very-low-density lipoproteins (VLDLs), high-density lipoproteins (HDLs), and chylomicrons. Elevated levels of blood lipids put a person at risk for cardiovascular disease. For your patient with diabetes, high lipid levels are particularly dangerous because diabetes itself is a risk factor for cardiovascular disease.Chylomicrons, which transport fats, break down in the liver and recombine into VLDLs, which consist mainly of triglycerides. Hyperinsulinemia and insulin resistance, common in patients with Type 2 diabetes, can trigger an overproduction of VLDLs, which may in turn trigger hypertriglyceridemia. Because insulin also stimulates the production of VLDLs, patients who use insulin must be particularly careful about eating fats.

LDLs transport cholesterol from the liver to the cells for deposit in peripheral tissues. An elevated LDL cholesterol level is strongly associated with the risk of heart disease. Taking the reverse route, HDLs transport cholesterol from peripheral tissues to the liver for catabolism and excretion. Increased levels of HDL cholesterol protect a person against heart disease.

Because HDL cholesterol levels are inversely related to triglyceride levels, many people with Type 2 diabetes have low levels of HDL cholesterol. This deficiency puts them at increased risk for developing atherosclerosis. As they gain better control over their blood glucose levels, their HDL cholesterol levels rise.

Patients can lower their blood lipid levels by reducing their total fat intake, losing weight, improving blood glucose levels, and changing the types of fat they consume. They should consume less than 300 mg of cholesterol per day. To help reduce cholesterol intake, patients with diabetes should eat no more than four egg yolks, the most concentrated source of cholesterol, per week.

Less than 10% of total daily calories should come from saturated fat. The acceptable amount of total fat per day, however, depends on your patient’s needs. Reducing total fat to 20% to 30% of calories reduces the risk of coronary artery disease for most people. This reduction calls for an increase in carbohydrate calories to 50% or more. While such a high-carbohydrate diet is healthy for people with Type 1 diabetes, it could increase blood glucose and triglyceride levels in insulin-resistant patients with Type 2 diabetes.

Saturated fat increases the risk of atherosclerosis by increasing levels of chylomicrons and LDLs. Most saturated fats come from dairy products, red meats, and other animal sources. Coconut oil, palm oil, and cocoa butter also contain saturated fats. Most of the fat in your patient’s diet should come from monounsaturated fats. Substituting monounsaturated fats for saturated fats may improve hypertriglyceridemia in patients with Type 2 diabetes without raising their LDL cholesterol levels. Sources of monounsaturated fats include canola, peanut, and olive oils. Your patient can also lower her cholesterol levels by substituting polyunsaturated fats-corn, sunflower, safflower, and soybean oils-for saturated fats.

Pancreas transplantation can improve the quality of life for your patient with Type1 diabetes by eliminating the need for insulin therapy, decreasing daily blood glucose measurements, and eliminating many diet restrictions. Transplantation also eliminates hypoglycemia.Pancreas transplantation is usually reserved for patients who will also receive a kidney transplant and immunosuppressive therapy. To be a candidate for pancreas and kidney transplantation, a patient must have a condition requiring kidney transplantation and must have significant complications with insulin therapy, such as frequent and severe hypoglycemia and insulin resistance. At some centers, surgeons transplant the pancreas alone to correct significant complications of diabetes in patients who don’t also have kidney disease.

Transplantation of the whole pancreas is the only therapy that reliably achieves euglycemia. However, the procedure is undesirable for most patients with Type 1 diabetes because of the risks of rejection and infection and because it requires lifelong immunosuppressive therapy.

As an alternative, a surgeon may transplant insulin-producing islet cells in a patient who is taking immuno suppressive drugs after receiving a transplanted kidney. In islet cell transplantation, the surgeon injects islet cells from the pancreas of a cadaver into the patient’s portal vein. The cells lodge in the liver and produce insulin, functioning as if they were in the pancreas. Before injection, the cells can be treated to destroy antigen-producing cells and reduce the risk of rejection.

Most patients continue to require insulin therapy after undergoing islet cell transplantation. For many, however, glucose control improves, and insulin requirements decrease. Some patients no longer need daily insulin injections.

Patients who have received both a pancreas and a kidney have had the best results. Acute rejection is more common, however, than in patients who receive a kidney alone. Surgical complications after pancreas-only transplantation are common, occur earlier, and lead to death in more cases.The most common complications after pancreas transplantation include rejection, infection, venous thrombosis, technical problems with duct anastomosis, and diabetes recurrence. Simultaneous kidney and pancreas transplantation causes more wound complications and a higher incidence of cytomegalovirus infection during the perioperative period than transplantations of the pancreas alone, but simultaneous transplantation poses no other long-term risks.

Hyperglycemia is one indication of rejection, but it doesn’t develop until 90% of the islet cell mass has become compromised, at which point rejection is usually irreversible. One benefit of simultaneous transplantation is that the condition of the transplanted kidney can help the physician predict the likelihood of pancreas rejection.

Up to 30% of transplant patients develop thrombosis of the vessels that supply the pancreas. Sites of surgical anastomosis can leak. After surgery, watch for hematuria related to the kidney vessels and irritation of the duodenal portion of the pancreas graft.

Infection from opportunistic organisms may occur as a complication of immuno suppressive therapy. Fever is a sign of both acute rejection and infection, so if your postoperative patient develops a fever, perform a thorough assessment. Unrecognized rejection can mean the loss of the transplanted organ. Unrecognized infection can lead to systemic inflammatory response syndrome and death.

For people with Type 2 diabetes, the first line of treatment is nutritional therapy coupled with exercise. If diet and exercise don’t control blood glucose levels adequately, a physician may prescribe oral antidiabetic drugs. These drugs, which are effective only when the pancreas continues to secrete at least some insulin, aren’t effective for patients with Type 1 diabetes.Sulfonylureas, which have been used to treat Type 2 diabetes since the mid-1950s, enhance the action of insulin. Second-generation sulfonylureas were approved for use in the United States in 1984, and one third-generation sulfonylurea was introduced in 1995. Other oral antidiabetic drugs used to treat Type 2 diabetes include metformin and acarbose, which lower blood glucose levels without stimulating the secretion of insulin. The oral antidiabetic drug, troglitazone, promotes the body’s sensitivity to insulin.