Diabetes in the CNMI

Diabetes is a disease that affects many on these islands.

Nearly everyone knows someone who is diabetic and it likely runs in most families.

Diabetes comes in 2 types basically.

Type I diabetes is also called juvenile diabetes because it often is discovered when patients are very young. In Type I diabetes, the body does not make insulin. Insulin is required for living and so if the body does not make it then it must be supplied. These are the patients that are on insulin every day and must take it every day to avoid diabetic ketoacidosis, which is life-threatening.

Far more common is Type II diabetes.

In Type II diabetes the body still makes insulin but it is either not enough or the body has a resistance to it.

While there is a large genetic predisposition to diabetes, here the main cause is being overweight and/or obese.

All of the complications of diabetes can be prevented for most people by losing weight and getting to a healthy size. Being overweight raises the level of insulin in your body but it raises the resistance to insulin within the body. Lack of activity, lack of exercise and poor eating habits make the problem even worse. In other words, if you have more body than you have insulin then you will become diabetic.

Many Type II diabetics do end up on insulin as their body’s ability to process insulin and sugar begins to fail.

Diabetics do not die of Type II diabetes although they can if the sugar gets high enough or if they develop electrolyte abnormalities due to untreated sugar.

Diabetics die of heart disease. Diabetics die from kidney failure. Diabetics die from losing limbs and losing their mobility. Diabetics go blind.

All of this can be prevented.

Keeping blood sugar levels controlled actually extends life.

When blood sugar rises the normal mechanism for transporting glucose (sugar) from the blood stream to the body is overwhelmed. Under normal conditions transport proteins are used to move sugar throughout the body. When sugar is too high the sugar tends to “leak” through the blood vessel walls, damaging the blood vessels as it does. The small vessels in the eye, the kidney and the heart are most affected but the vessels in the legs and feet are also subject to damage.

This is why the treatment strategies for diabetes have emerged.

Initially the diabetic is started on a diet. Carbohydrate restriction and healthy eating can sometimes help control diabetes and medication might not be required.

If a medication is required, ideally one starts with an oral medicine such as metformin. Metformin causes less glucose to be released from the liver and also helps boost sensitivity to existing insulin and to decrease absorption of glucose in the diet. This helps to control blood glucose and often can be the only medicine you need. There are numerous medications we can draw from to treat diabetes if metformin is not enough or is not tolerated. Many have been around for years and there are some new ones. Some are less likely to cause hypoglycemia or low blood sugar than others.

In addition to controlling the blood sugar diabetics are also started on either an ACE inhibitor (angiotensin converting enzyme inhibitor) or an ARB (angiotensin receptor blocker). This step is necessary not only for blood pressure control but also to protect the kidneys against the diabetes. They help to delay or prevent protein in the urine, which is very damaging to the kidneys and indicates significant kidney damage.

Diabetics should also be on a statin medication if they tolerate them. Again, specifically in diabetic patients, this has shown to prolong life and perhaps protect the heart from the ravages of diabetes.

In addition, diabetics should have at a minimum one eye exam per year. More often if your eye specialist recommends them. The small vessels in the eyes are easily damaged by sugar and high sugar can also cause growth of new vessels which will rob the patient of their eyesight. When caught early it is highly treatable.

Diabetics should have a urinalysis at least once or twice a year to check for microalbumin, an early warning sign of kidney damage.

Diabetics must be very careful about their feet. Lesions on the feet can become infected very easily due to the damage to blood vessels in the legs and feet. Often this ends with amputation as the whole limb dies off. Proper fitting shoes are a must and it really is inadvisable for a diabetic to walk around barefoot. Diabetics must be aware of hot water and make sure that baths are the right temp before getting in. Since the diabetic foot is often numb, serious burns can occur which can become infected and lead to loss of limbs.

But the biggest thing that most diabetics can do is to lose weight.

Weight loss restores your body’s utilization of insulin and contributes to overall health and wellbeing.

Low carb diets are the easiest for diabetics to follow but any weight loss regimen is better than nothing.

Exercise is essential. At least 30 minutes three to four times a week. Walking is a good exercise. Longer periods of exercise are helpful as well but the 30-minute mark will get you started.

Diabetes is a major risk factor for heart disease. A diabetic should have their blood pressure under good control and their blood sugar under good control. They should be on a statin medication as mentioned above and should not smoke.

Contrary to popular belief, brown rice and white rice have about the same amount of sugar in them. If it has carbohydrates in it then it has sugar.

Carbohydrates are not found in fish, chicken, pork or beef unless they are processed. While too much red meat can be disadvantageous or even bad for you, the weight loss and sugar control offset that for the limited time one would be on the diet. If it swims, crawls, walks, runs or flies, it is fair game. There are low carbohydrate vegetables available as well. Just read the labels or look online.

Talk to your healthcare provider about your risks for diabetes and what you can do to minimize the risks and if you are already diabetic then start on your weight loss and work with your doctor to keep you at peak fitness while you diet, exercise, and heal your body.

Dr. John L. Doyle III is a physician at Marianas Medical Center.