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An in-depth report on how people with diabetes can eat healthy diets and manage their blood glucose. HighlightsGeneral Recommendations for Diabetes DietPatients with pre-diabetes or diabetes should consult a registered dietician who is knowledgeable about diabetes nutrition. Science, Technology and Medicine open access publisher.Publish, read and share novel research. Fulminant Type 1 Diabetes Mellitusin IRS-2 Deficient MiceToshiro Arai1, Nobuko Moriand1 and Haruo Hashimoto1[1] Nippon Veterinary and Life Science University, Japan1. 2007 Fulminant type 1 diabetes in Korea: highprevalence among patients with adult-onset type 1 diabetes. 2003 Inflammatory mediators and islet ?-cell failure: a link between type 1and type 2 diabetes.
2009 Reconsideration of 2sulin signals induced by improved laboratory animal diets, Japanese and American diets, in IRS-2 deficient mice. 2000 A novel subtype of type 1 diabetes mellitus characterized by a rapid onsetand an absence of diabetes-related antibodies. 2005 Different contribution of class II HLA in fulminant and typical autoimmune type 1 diabetes mellitus. 2000 Tissue-specific insulin resistance in mice withmutations in the insulin receptor, IRS-1, and IRS-2.
2000 Disruption of insulin receptor substrate 2 causes type 2 diabetes because of liver insulin resistance and lack of compensatory beta-cell hyperplasia. 2002 Increased expression of antioxidant and antiapoptotic genes in islets that may contribute to beta-cell survivalduring chronic hyperglycemia.
2001 Distict effects of saturated and monosaturated fattyacids on beta-cell turnover and function.
1997 Glycation-dependent, reactive oxygen species-mediated suppression of the insulin gene promoter activity in HIT cell. Suggested citation for this article: James-Todd TM, Karumanchi SA, Hibert EL, Mason SM, Vadnais MA, Hu FB, et al. Women with a history of gestational diabetes mellitus (GDM) are at higher risk of developing type 2 diabetes (T2DM); however, little is known about the association between other common pregnancy complications (eg, preterm birth, macrosomia) and T2DM risk.
Women who experienced a very preterm birth or had an infant that weighed 10 pounds or more may benefit from lifestyle intervention to reduce T2DM risk. A growing body of research suggests that pregnancy and the period surrounding it may provide unique information about a woman’s future risk of chronic disease (1,2). Despite the well-established association between GDM and future risk of T2DM (5,8), less is known about even more common pregnancy complications and future risk of T2DM.
The objective of our study was to examine the association between gestational age, birth weight, and T2DM in mothers.
Study participants were from the Nurses’ Health Study II (NHSII) population, a cohort study of 116,678 female nurses who were aged 25 to 42 years at the start of the study in 1989. Our study population is based on a subset of the NHSII population who had detailed data on pregnancy history and T2DM. Study participants indicated the length of each of their 5 most recent pregnancies lasting at least 12 weeks in the following categories: 12 to less than 20 weeks, 20 to less than 24 weeks, 24 to less than 28 weeks, 28 to less than 32 weeks, 32 to less than 37 weeks, 37 to 42 weeks, and 43 or more weeks. In the NHSII 1989 baseline questionnaire and subsequent biennial questionnaires study participants indicated whether they had ever been diagnosed with GDM by a physician.
NHSII study participants received a supplemental questionnaire if they reported having been diagnosed with diabetes mellitus on the biennial questionnaires between 1991 and 2005.
On the 1989 baseline questionnaire, study participants reported their current weight and height and their weight at age 18 (19).
We used Cox proportional hazards models to examine the association between preterm and postterm birth, as well as low birth weight and macrosomia with T2DM risk, modeling gestational age and birth weight separately. Women were followed from their first birth through 2005 or up to 35 years after their first pregnancy; we were able to follow more than 95% of the cohort for up to 34 years after their first birth. In our study population of NHSII participants, births occurred between 1964 and 2001, with 95% occurring before 1993. In age-adjusted analysis, we observed a graded association of very and moderate preterm birth with risk of T2DM, as well as elevated risks among women delivering their first child postterm (Table 2). We explored the association between gestational age and T2DM in 5-year intervals following first pregnancy (Figure 2).
When evaluating absolute risk of T2DM for women who delivered an infant that weighed 10 pounds or more, we found an excess of 115 T2DM cases per 10,000 women in this group compared with women who delivered a normal weight infant in the 21 to 25 years following the first pregnancy. Because the prevalence of screening for GDM and HDOP during pregnancy has changed over the period of the births in this cohort (1964–2001), we repeated the analysis among first births occurring after the baseline 1989 questionnaire, because after that time period, screening was more widely practiced as standard care and gestational age-dating of pregnancies had probably improved with the advent of ultrasound.
In this study, the approximately 9% of women whose first infant was delivered preterm had excess risk of developing T2DM, even after accounting for potential medical and lifestyle confounders.
In a previous study by Lykke et al based on vital statistics registry data from Denmark (23), preterm birth (<37 weeks) was associated with a 2-fold increased risk of T2DM in mothers after adjusting for maternal age, year of delivery, and pregnancy complications.
The increased risk of T2DM among women who experience a preterm birth may be due to chronic low-level inflammation (25,26). Strengths of this study include use of a large cohort of nurses with detailed information on both pregnancy history and diabetes and information on pre-pregnancy and reproductive risk factors for diabetes. Women who experience a preterm birth or have an infant with nonnormal birth weight are not followed up for lifestyle intervention or disease prevention after re-entry into the standard health care system for nonpregnant women. American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Obstetrics. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Patient empowerment: reflections on the challenge of fostering the adoption of a new paradigm.
The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the Chronic Care Model. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. 2008a Promocion de la salud para la disminucion del riesgo y el cuidado de las enfermedades cronicas. Validation of a counseling strategy to promote the adoption and the maintenance of physical activity by type 2 diabetic subjects. 2007 The use of Goal Attainment Scaling in a community health promotion initiative with seniors. Classic T1DM is an autoimmune disease that occurs because of loss of insulin production by the pancreas as a result of destruction of the beta cells. Children with T1DM are at increased risk for other autoimmune diseases, such as celiac disease, autoimmune thyroid disease, and adrenal insufficiency.
Poorly controlled T1DM can lead to potentially life-threatening short- and long-term conditions that range from subtle neurocognitive changes to organ-destroying macrovascular and microvascular damage (Table 1).3 The age at onset of the illness has implications for complications that can arise from hypoglycemia (tremor, confusion, seizures) and hyperglycemia (nocturia, ketoacidosis, coma, microvascular changes).
The preschool-age child is more prone to hypoglycemic episodes that may lead to problems with spatial memory deficits, compromised cognitive function, and lower gray matter volume in the left superior temporal region.
Older children and adolescents are less vulnerable to nocturnal hypoglycemia and to neurocognitive changes. The impact of chronic illnesses for children and adolescents and their family functioning has been well described since the 1970s, and studies of psychiatric comorbidity have been reported since the 1980s.
Treatment for type 1 diabetes mellitus (T1DM) has progressed remarkably over the past 10 years with insulin pumps and continuous glucose monitoring, yet challenges remain for affected youths and their families. For the psychiatrist treating a child or family member with T1DM, assessing the functioning of the family and the patient for psychiatric comorbidity is vital. At the time of diagnosis, parents and older children are faced with the daunting task of learning a great deal of information rapidly and the need to shift priorities to include glucose monitoring and insulin administration. The impact at the time of diagnosis on the family is often one of shock followed by acceptance. The impact of family functioning on childhood T1DM was described by Minuchin and colleagues9,10 in the 1970s. Understanding the Effects of Roux-en-Y Gastric Bypass (RYGB) Surgery on Type 2 Diabetes MellitusRaymond G.
Why there is this discordant finding between HOMA-IR measures and insulin clamp studies is unclear.
An experienced dietician can provide valuable advice and help create an individualized diet plan.Even modest weight loss can improve insulin resistance (the basic problem in type 2 diabetes) in people with pre-diabetes or diabetes who are overweight or obese.
Dietary control in type 1 diabetes is very important and focuses on balancing food intake with insulin intake and energy expenditure from physical exertion.
Effects of modern Japanese and American diets on RNA expression of GLUT4 and PPAR?2 of adipose tissues and plasma adipocytokines concentrations in IRS-2 deficient mice fed with three kinds of diets with different lipid levels.
Effects of modern Japanese and American diets on intraperitoneal white adipose tissues, (a) Axial views, (b) Coronal views of MRI, and (c) Adipocytes in white adipose tissues of IRS-2 deficient mice with three kinds of diets with different lipid levels. IntroductionType 1 diabetes mellitus (T1DM), one of two major forms of diabetes, results from nearly complete destruction of pancreatic beta (?) cells. We examined the associations between first-pregnancy preterm, postterm birth, low birth weight, and macrosomia with subsequent risk of T2DM. If replicated, these findings could lead to a reduced risk of T2DM through improved primary care for women experiencing a preterm birth or an infant of nonnormal birth weight.
For example, gestational diabetes (GDM) is a well-established risk factor for type 2 diabetes (T2DM) in women (3,4). For example, preterm birth and low birth weight complicate more than 10% of US pregnancies (9,10). We evaluated these associations in a large cohort study, adjusting for potential confounders, including maternal and paternal history of diabetes, pre-pregnancy body mass index (BMI), and smoking during pregnancy. NHSII follows participants biennially by questionnaire to obtain both health-related behavior information and data on the occurrence of diseases, including diabetes. More specifically, in 2001, NHSII sent a supplemental questionnaire to study participants who were deemed good responders — those women who typically responded to the first or second mailing of the biennial questionnaires. Characteristics of the study population, 2001 Nurses’ Health Study II supplemental questionnaire. Low birth weight was defined as less than 5.5 pounds at term and macrosomia as 10 pounds or more at term.
A validation of GDM showed high validity of self-report of this condition compared with medical records (16).
A recent validation of pre-eclampsia compared with medical record review showed self-reported preeclampsia is a moderately good indicator of hypertensive disorders of pregnancy (HDOP) (positive predictive value, 73%) (17). These supplemental questionnaires collected information to distinguish between type 1 and type 2 diabetes mellitus on the basis of diabetes diagnosis and treatment. Subsequent biennial questionnaires queried family history of diabetes mellitus, as well as a personal medical history (eg, hypertension, cancer, gestational diabetes, pre-eclampsia, toxemia). Very preterm birth, moderate preterm birth, and postterm birth were evaluated as indicator variables, with the reference group of term.
First, we evaluated the association between gestational age, infant birth weight, and T2DM risk in first pregnancies for the entire 35-year follow-up period.
We examined pregnancy complications and risk factors for all births and for term births in the study population (Table 1). In the first decade after very preterm birth, there was no increased risk of T2DM compared with term birth. We found that during the 6 to 10 years following the first pregnancy, only 12 excess T2DM cases per 10,000 women who experienced a moderate preterm birth occurred compared with women who delivered at term.
After 30 years, the elevated risk associated with having delivered a large infant had disappeared. The hazard ratios estimated by the fully adjusted models (including GDM and HDOP diagnoses) were stronger for birth weight and T2DM, which mitigated the concern that macrosomia in the earlier pregnancies might merely be a marker for undiagnosed GDM.
The 2% of women who experienced a very preterm birth had a 34% increased risk of developing T2DM over the 35-year follow-up period. Several studies suggest that chronic low-level inflammation precedes the onset of T2DM (26–28).
Both the American Diabetes Association and American College of Obstetrics and Gynecology recommend screening for T2DM for women with a history of GDM (32,33). UL1 RR 025758 and financial contributions from Harvard University and its affiliated academic health care centers). Mortality of mothers from cardiovascular and non-cardiovascular causes following pregnancy complications in first delivery. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Prepregnancy lipids related to preterm birth risk: the coronary artery risk development in young adults study.
Inflammatory cytokines and spontaneous preterm birth in asymptomatic women: a systematic review.
Hypertensive pregnancy disorders and subsequent cardiovascular morbidity and type 2 diabetes mellitus in the mother. Preterm delivery and risk of subsequent cardiovascular morbidity and type-II diabetes in the mother.
Severe obstetric complications and birth characteristics in preterm or term delivery were accurately recalled by mothers.
The retrospective measurement of prenatal and perinatal events: accuracy of maternal recall. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.
Types of support that individuals can offer through social networks of social support in Community Programs for prevention and control of Diabetes Mellitus.. IntroductionThe health of the population is a product of the society and at the same time an indispensable contribution to economic growth and political stability. Ideal treatment requires close monitoring of blood glucose levels by finger pricks 5 to 10 times daily and insulin injections with all carbohydrate intake and as often as every 2 hours for corrections of blood glucose levels. Fortunately, treatment for T1DM has advanced greatly over the past 10 years, and medications such as insulin detemir have greatly reduced the risk of severe nocturnal hypoglycemia.7 With the increased risk of hypoglycemic episodes for the preschool-age child with T1DM, the struggle with care and dietary control as the child transitions into school may occur. He had a severe episode of hypoglycemia when he was 4, and his parents were instructed to “let his sugars run a little high.” As he was getting older, he was able to clearly tell his parents when his sugar was low, and more strict control was instituted. The consequences of longer-term poorly controlled diabetes, as evidenced by elevated hemoglobin A1c levels associated with microvascular changes, such as renal failure, retinopathy, and neuropathies, usually do not present until early adulthood. This article summarizes recent findings on neuropsychological effects of short- and long-term consequences of hypoglycemia and hyperglycemia, use of evidence-based family treatments for families struggling with T1DM, and the impact of psychiatric comorbidity on outcomes for the patient with T1DM and family members. Teasing out behavioral challenges from the disease necessitates close contact with the medical care providers.
Family functioning is stressed by the treatment regimen that may be uncomfortable and painful and out of alliance with the normal tasks of development.
Because of dietary restrictions, meal structure and appropriate food choices also become more difficult. They described families with a diabetic child as vulnerable to 4 maladaptive transactional patterns: enmeshment, overprotectiveness, rigidity, and lack of conflict resolution. Weight loss over 15 years between control groups (blue), gastric banding (orange), vertical banded gastroplasty (purple), and gastric bypass (green).3. Are there available studies that compare effective calorie restriction versus RYGB in terms of diabetes improvement?
Although HOMA-IR is an index of insulin sensitivity, it may also be used as a surrogate for hepatic insulin sensitivity. Relationship Between Obesity and Diabetes in a US Adult Population Findings from the National Health and Nutrition Examination Survey, 1996-2006. Reduction in Weight and Cardiovascular Disease Risk Factors in Individuals with type 2 diabetes: one year results of the look AHEAD trial. Comparison of Glucostatic Pamaeters After Hypocaloric Diet or Bariatric Surgery and Equivalent Weight Loss.
Effect of Weight Loss by Gastric bypass Surgery Versus Hypocaloric Diet on Glucose and Incretin Levels in Patients with Type 2 Diabetes.
Propsective Study Of Gut Hormone and Metabolic Changes after Adjsutable Gastric Banding and Roux-en-Y Gastric Bypass. Re-emergence of diabetes after gastric bypass after gastric bypass in patients with mid to long term follow up. Refractory and new-onset diabetes more than 5 years after gastric bypass for morbid obesity. Improvement of Type 2 Diabetes Mellitus After Bariatric Surgery-Who Fails in the Early Postoperative Course? Physical activity, even without weight loss, is also very important.The American Diabetes Association (ADA) encourages consumption of healthy fiber-rich foods including fruits, vegetables, whole grains, and legumes. Type 2 DiabetesType 2 diabetes is the most common form of diabetes, accounting for 90 - 95% of cases.
All pancreas specimens were fixed in 10% buffered formalin and embedded paraffin, mounted on amino-silane coated glass slide and stained using the indirect immunoperoxidase method. Excess calorie and physical inactivity induce hyperglycemia followed by increased insulin secretion, which accelerates fatty acid synthesis via activation of transcriptional factor, SREBP-1c etc. Although up to 70% of women who develop GDM will eventually develop T2DM within the first 5 to 20 years following pregnancy (5), several studies have shown that lifestyle interventions immediately following pregnancy lead to a significant reduction in T2DM risk (6,7). We also adjusted for lifestyle and reproductive factors as well as pregnancy complications known to be predictors of T2DM.
In addition, the 2001 supplemental questionnaire asked about smoking status during pregnancy (eg, ever, never). For the association between birth weight and T2DM, we did not have enough information on birth weights under 5.5 pounds to create small-for-gestational-age categories among preterm births. Second, we explored time since first birth in 5-year intervals up to 35 years after the first pregnancy to determine at what time points the differences between gestational age or birth-weight groups were significant. However, there was an inconsistent change in risk in the second decade, which reached statistical significance. By 26 to 30 years after the first pregnancy, 298 excess T2DM cases per 10,000 women who delivered a very preterm birth occurred compared with those who delivered at term. Associations between macrosomia and subsequent risk of T2DM were only significant between 6 and 20 years after the first pregnancy.
However, the association of very preterm delivery with T2DM was no longer detectable when limiting the analysis to pregnancies occurring after 1989. In an exploratory analysis, we found that the elevation in risk first became evident at 11 to 15 years after the first pregnancy.
As such, preterm birth could signal a chronic state of inflammation and an increased risk of future development of T2DM. In addition, this study had an average follow-up time after first birth of 22 years, which allowed for sufficient time for a substantial proportion of participants to develop the disease (approximately 4% of the population).
However, validation studies demonstrated good self-report of related pregnancy factors (16,19). If our findings are replicated, women who experience a preterm birth or have a nonnormal birth-weight infant may benefit from additional follow-up and lifestyle intervention to reduce their subsequent risk of T2DM.
The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, or the National Institutes of Health.
Vadnais, Howard Hughes Medical Institute, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts; Eileen L. Community United for Human Growth linked to Institutions of Higher Education in Health is responsible for the design and implementation of educational programs and guides the training of the health promoters for the development of mutual-help groups (human development nucleus).
In Latin America, the Program for Education of Non-insulin-dependent Diabetics-Latin America (PEDNID-LA) was proposed, which was implemented simultaneously in Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Mexico, Paraguay, and Uruguay, demonstrating satisfactory results for the adoption of healthy lifestyles (Gagliardino & Etchegoyen, 2001).
For those afflicted with celiac disease, dietary modifications necessitate a gluten-free diet in addition to the recommended restrictions for simple sugars and the need to avoid grazing. In first grade, with less supervision in the cafeteria, Timmy learned to sneak favorite higher-sugar foods, which resulted in more aggressive behavior, difficulty in sitting still, and acting more “wild.” His parents reported difficulties with adhering to dietary recommendations and with his tendency to “get wild” when he couldn’t get away with unapproved foods or behaviors. Evidence-based treatments, such as multisystemic treatment, cognitive-behavioral therapy, psychoeducation, and prudent psychopharmacology, are tools for the psychiatric provider. Because of the potential for immediate life-threatening complications of poorly controlled diabetes, family members must readjust their approach to daily living.
Children with T1DM are expected to follow up with the diabetes care team at least every 3 months and sometimes more often if they or family members cannot maintain tight glycemic control. In addition, Minuchin’s group reported that stressful family interactions could lead to immediate elevations in the patient’s blood glucose levels.
Brathwaite1 and Louis Ragolia3[1] Department of Bariatric Surgery, Winthrop University Hospital, Mineola, New York, USA[2] Department of Endocrinology and Metabolism, Winthrop University Hospital, Mineola, New York, USA[3] Department of Vascular Biology, Winthrop University Hospital, Mineola, New York, USA1. While most accurate in assessment of glucose uptake of in vivo systems, it requires experienced and skilled personnel often not readily available. Therefore, one may observe there are more rapid improvements of hepatic insulin sensitivity than that seen with peripheral insulin sensitivity.
In type 2 diabetes, the body does not respond normally to insulin, a condition known as insulin resistance. Pancreas sections were pretreated with 0.03% H2O2 in methanol to block endogenous peroxidase activity, and incubated for 60 min at room temperature with guinea pig anti-swine insulin (Dako Cytomation), followed by 30 min incubation with peroxidase-conjugate rabbit anti-guinea pig immunoglobulin.
For each mouse, sera were treated with 0.03% H2O2 in methanol to measure the endogenous peroxidase activity. Acceleration of fatty acid synthesis induces heterotopic accumulation of lipid, and visceral fat accumulation is increased. Preterm birth and low birth weight share common underlying risk factors with T2DM, including elevated pre-pregnancy and pregnancy lipid concentrations (11,12) and inflammatory markers (13,14). Finally, we explored the time trends in risk over the decades following birth of a preterm infant or an infant of nonnormal birth weight to suggest potential windows for prevention and glucose tolerance screening after complicated pregnancies. The 6% of respondents who reported having diabetes on the baseline 1989 questionnaire were not sent the supplemental questionnaire and, consequently, had details only on date of diagnosis, without information on whether the diabetes was type 1 or type 2.
BMI was derived for ages at which weight was not reported (ie, between age 18 and age at the baseline questionnaire) from a formula using weight at age 18 and weights reported on biennial questionnaires, as well as somatograms at ages 20, 30, and 40 to assign BMI at each age starting at 18 years and through the end of the study period.
Participants were also asked at baseline to report their menstrual regularity at age 18 to 22 years, which was categorized as regular, irregular, or no menstrual periods.
No significant associations were found after 21 years following first pregnancy among women with a very preterm birth. Postterm birth was associated with a slight, significant increase in risk of T2DM over the entire 35-year period.
Another study by Catov et al found 76% increased odds of metabolic syndrome among women with a previous preterm birth 8 years following pregnancy (24). In addition, the association between macrosomia and T2DM, independent of GDM status, could be attributed to maternal hyperglycemia, which is less overt than GDM and can lead to fetal hyperglycemia, exaggerated fetal insulin response, and macrosomia. Furthermore, we were able to explore these research questions by using different cut points in total study time. Also, several validation studies show moderate to high reliability of self-report of preterm birth and infant birth weight when compared with medical records (29–31). A human development nuclei is a group integrated by 10 to 15 adults of nearby communities with similar interests. In this regard, it is necessary for the Ministry of Health to forge alliances with other public and private actors, including organizations of the civil society, because it has been shown recently that one of the key elements that contribute to maintenance of health is the support that is received from interpersonal interaction. In Mexico, the Ministry of Health’s General Directorate of Health Promotion developed the Health Promotion Operational Model in 2006.
Needless to say, for the child or teen with both T1DM and celiac disease, the dietary modifications can significantly affect the quality of their lives (eg, no pizza with friends, no cake and ice cream at birthday parties, and no on-the-go diet favored by teens). One such study by Plum et al demonstrated greater improvement in diabetes in RYGB subjects when compared to low calorie diets over three months [13].
The small body of literature that uses clamp data in gastric bypass subjects supports that insulin sensitivity in the post-operative period correlates with weight loss [31, 33], and therefore, is not a weight independent event in both diabetics and non-diabetics. It is possible glycemic variability is a precursor to the metabolic complication post-gastric bypass hypoglycemia.
The ADA has found that both low-carb and low-fat diets work equally well, and patients may have a personal preference for one plan or the other.Patients with kidney problems need to limit their protein intake and should not replace carbohydrates with large amounts of protein foods. Then, the sections were incubated for 60 min at room temperature with rabbit anti-human glucagon (Dako Cytomation), followed by 30 min incubation with alkaline phosphatase-labelled polymer conjugated goat anti-rabbit antibody (Nichirei).
We defined low birth weight as an infant born at term weighing less than 5.5 pounds, and we defined macrosomia as an infant born at term weighing 10 pounds or more. Moderate preterm and term low birth weight did not significantly increase the risk of T2DM over the 35-year follow-up time. These shared biological factors suggest that preterm birth and low term birth weight may be early markers of subclinical risk of future development of T2DM.
To restrict the analysis to cases likely to be T2DM, we included women who reported having diabetes mellitus on the 1989 questionnaire only if they were age 30 years or older at the time of diagnosis.
Models were constructed among all term births by using indicator variables for low birth weight, macrosomia, and normal birth weight (reference group). We adjusted for potential confounders, those factors that preceded pregnancy complications of interest and were associated with diabetes mellitus. In contrast, women who had a moderate preterm birth had significant, roughly two-fold, increased risk of T2DM for the first 10 years after their first pregnancy, which thereafter returned to the baseline risk of women who had delivered at term. A history of having borne a first infant who was term low birth weight or macrosomic conferred an almost 2 to 3-fold increased risk of T2DM, which gradually waned over time. We observed a very similar 2-fold increased risk of T2DM after a moderate preterm delivery (<37 weeks) in the first 10 years after pregnancy. Therefore, macrosomia could simply indicate hyperglycemia in mothers, despite not meeting clinical definitions for a GDM diagnosis. This technique allowed us to explore periods in which certain pregnancy complications may have the most predictive value for future development of T2DM. Second, we used categories of gestational age and birth weight instead of continuous measures, which may make it difficult to see subtle changes in disease risk.
They are mainly involved in the practice of self-care, mutal-help, and self-promotion guidelines established by the program. At present, there has been a significant increase worldwide of chronic degenerative diseases, among which Diabetes mellitus (DM) is prominent.
Based on Ottawa Charter functions, the model integrates health promotion activities within the overall health care system (Santos-Burgoa et al., 2009). His parents and school worked with a pediatric psychologist to establish a positive behavioral system that resolved Timmy’s behavior problems. Both groups had similar amounts of weight loss, suggestive that RYGB has weight independent effects on diabetes.The surgical obesity procedure known as the gastric band may be perceived as a superior “control group” to dietary weight loss. Only Kashyap et al [34] demonstrated a slight increase of insulin sensitivity using clamp studies at one week following surgery for subjects that underwent gastric bypass as compared to gastric banding.
HOMA-IR and peripheral insulin sensitivity were assessed through clamp studies, with individuals undergoing RYGB one month following surgery by Lima et al [36]. Our laboratory is involved in trials studying this effect.There are a greater number of studies examining the changes of insulin resistance in those that undergo RYGB and caloric restriction. In type 2 diabetes, the initial effect is usually an abnormal rise in blood sugar right after a meal (called postprandial hyperglycemia).Patients whose blood glucose levels are higher than normal, but not yet high enough to be classified as diabetes, are considered to have pre-diabetes.
For double staining, peroxidase (brown, DAB) and alkaline phosphatase (red, New Fuchsin) were used, respectively. In addition, giving birth to a macrosomic infant (10 pounds or more) could suggest an increased risk of future maternal T2DM in the absence of GDM or could result from undiagnosed GDM. Finally, we used the Breslow estimator to calculate the age-adjusted risk differences from the Cox proportional hazards models. These findings held even after adjusting for GDM and HDOP, known predictors of T2DM (8,20–22). However, we were able to follow our cohort for an additional 20 years, which indicated that the excess risk associated with a history of moderate preterm birth was limited to the first 10 years after pregnancy. In fact, the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study found a continuous association between maternal hyperglycemia and increasing birth weight (15).
Future studies are needed to further explore and confirm these associations based on time since pregnancy.
Furthermore, these categorizations prevented us from examining small-for-gestational age or large-for-gestational-age infants; as such we had to restrict our analysis of birth weight to term births.
However, the results relative to the implementation and effectiveness of the model have not been reported. The gastric band is an anatomically enforced form of caloric restriction and can be difficult to “cheat.” Diabetes remission in subjects who had the gastric band has been shown to be directly related to weight loss, and was superior to conventional therapy programs [8].
However, as with all control groups, it is unclear if the oral intake of gastric band subjects was equivalent to the RYGB study group. They demonstrated that there was no improvement of peripheral insulin resistance despite weight loss, although HOMA-IR did improve.
There are far fewer studies comparing these two groups and assessing for differences in beta cell function. It is very important that people with pre-diabetes control their weight to stop or delay the progression to diabetes.Obesity is common in patients with type 2 diabetes, and this condition appears to be related to insulin resistance. Thus adiponectin increases glucose uptake and fatty acid oxidation in muscles via the type 1 adiponectin receptor (Yamauchi et al., 2003), and hepatic gluconeogensis via type 2 adiponectin receptor. For example, T2DM could result from excess glucose exposure and consequent high fetal growth from impaired glucose tolerance that falls short of GDM diagnostic criteria (15). If our findings are replicated in future studies, gestational age and offspring birth weight may be useful to identify high-risk women. The risk associated with very preterm birth, however, arose after the first decade following the first pregnancy and remained modestly elevated throughout the 35 years of follow-up. Thus, our finding of an early elevation in T2DM risk for women who delivered infants that were term low birth weight may not be generalizable to women who delivered preterm infants, who were small for gestational age.
Rich-Edwards, Brigham and Women’s Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts. In this respect, the International Diabetes Federation estimates that 285 million people around the world suffer from DM. It contributes to significant morbidity and mortality including heart disease, stroke, cancer, arthritis and sleep apnea.
However, prospective longitudinal studies comparing RYGB to gastric banding have demonstrated that RYGB promotes greater insulin sensitivity along with superior weight loss at one year [16].
Further molecular studies in rodent models that have undergone RYGB support the notion that insulin sensitivity is weight dependent.
Dunn et al used more dynamic and definitive methods for assessing hepatic insulin resistance using hyperinsulinemic euglycemic clamp studies with isotropic tracers, while also collecting data to asses for peripheral insulin resistance.
One study by Hofso D et al [50] compared RYGB to “intensive lifestyle intervention” as the nearest appropriate control. Moreover adiponectin protects against oxidative stress in skeletal muscle by activating nuclear factor (NF)-?B target genes, manganese superoxide dismutase and inducible nitric oxide synthase (Ikegami et al., 2009).
If such associations are found, women experiencing these complications could potentially benefit from early intervention to reduce future T2DM risk. Our exploratory analysis , if replicated, may also provide information on time windows in which glucose tolerance screening might be an effective addition to the primary care of high-risk women.
However, the weakening over time of relative risk associated with preterm delivery and infant birth weight may reflect the increasing prevalence of other T2DM risk factors with increasing age (study time), including high BMI and increased sedentary behaviors.
The model is based fundamentally on the integral development of the person, understood as a process that is carried out throughout and until the end of the person’s lifetime.
Additional other types of studies have validated the potency of RYGB on diabetes through the use of other controls. GLUT4 mRNA expression in skeletal muscle and adipose tissue of rodents that have undergone RYGB, does not increase until 28 days after surgery [35]. They also demonstrated that there was also improvement in hepatic insulin sensitivity as compared to no improvement of peripheral insulin sensitivity at one month [37]. However, as expected, RYGB achieved superior weight loss, with significantly improved beta cell function. With regular exercise and diet modification programs, many people with type 2 diabetes can minimize or even avoid medications. Column 1, 2 and 3 present diabetic NOD, control IRS-2 deficient and diabetic IRS-2 deficient mouse pancreatic sections, respectively.
However, epidemiological study of FT1DM is lacking in other Asian populations and its incidence and pathogenesis remain to be elucidated.
Decreased adiponectin secretion and increased inflammatory cytokines secretion from swelling adipose tissue deteriorate insulin resistance in obese animals (1st stage).
Therefore, our findings may suggest that these pregnancy complications may be especially useful predictors of early-onset T2DM. Finally, we had limited ability to evaluate this association among minorities, who have both a higher prevalence of these pregnancy complications and T2DM.
Each year, an additional seven million persons develop diabetes (International Diabetes Foundation [IDF], 2011).
It implies becoming active in many ways, making use of and potentiating the resources possessed.
One such study by Adams et al [17] was a large retrospective study of several thousand, comparing RYGB subjects to weight matched controls.
The reason for this requires further research.Although RYGB and insulin secretion will be discussed in a later section, there are few studies that have measured hepatic glucose output in subjects that have undergone RYGB. There are no available or appropriate weight matched trials to compare diet to RYGB on beta cell function.The anatomic and histologic changes brought on by RYGB on the pancreas are also not well studied, due to the inability to easily access pancreatic tissue. Within 10 minutes after a meal insulin rises to its peak level.Insulin then enables glucose to enter cells in the body, particularly muscle and liver cells. Weight loss medications or bariatric surgery may be appropriate for some patients.General Dietary GuidelinesLifestyle changes of diet and exercise are extremely important for people who have pre-diabetes, or who are at high risk of developing type 2 diabetes. Control NOD mouse serum (A) reacted with diabetic NOD (A1), control IRS-2 deficient (A2) and diabetic IRS-2 deficient mouse (A3) pancreatic sections.
Decreased adiponectin causes depression of activity of AMPK which increases glucose utilization and fatty acid ?-oxidation in skeletal muscle and adipose tissues (Whitehead et al., 2006). This disease is the leading cause of death in Mexican population and is the most cost-intensive item for the nation’s health care system. It is a process of transformation and continuous growth in which the social capital is fundamental. Results from various studies have shown that weight reduction significantly reduces the risk of developing T2DM in obese individuals [3], as well as improving glycemic control in those already with T2DM [4,5]. Because insulin clamp studies are the gold standard in assessment of peripheral insulin sensitivity, the rapid glycemic improvement seen immediately following surgery appears not due to increased peripheral glucose uptake.
Dunn et al [37] demonstrated decreased hepatic glucose production using clamp studies as described earlier. The body of literature of known histologic or molecular changes within the pancreas that have been observed are restricted to rodent models, or those afflicted with post-gastric bypass hypoglycemia. Lifestyle interventions can be very effective in preventing or postponing the progression to diabetes.
Diabetic NOD (B1-3), control IRS-2 (C1-3) and diabetic IRS-2 (D1-3) mouse sera reacted with pancreatic sections, respectively. Then hyperglycemia, hyperinsulinemia and accelerated lipid synthesis are maintained and hyper-secretion of insulin force excessively heavy work on pancreatic ? cells. The majority of patients with diabetes in Mexico are in poor metabolic control (Villalpando et al., 2010a).
Long term medical therapy for obesity is often unsuccessful for the majority of patients in clinical practice. Despite the overall lack of prospectively randomized control trials, there has been compelling data to demonstrate RYGB effectively treats hyperglycemia and the diabetic state. One may expect hyperinsulinemia, especially in the setting of a marked peak in the postprandial insulin level. In over functional pancreatic islets, ?-oxidation of fatty acid is accelerated resulting in excess amount of reactive oxygen species (ROS) production, which induces ROS stress leading to mitochondrial dysfunction and apoptosis of ?-cells with low scavenging activity of ROS (2nd stage). In this respect, the current care model has not been effective for the prevention and control of DM. Bariatric weight loss surgery has remained the most effective means of achieving and maintaining weight loss.
Only in 2012 were the first prospectively, randomized, non blinded controlled studies made available, comparing weight loss surgery to medical weight loss therapy. Contrary to these findings, Camastra et al [33] showed no improvement of endogenous glucose production one week following surgery against BMI matched controls. However, if the AUC of postprandial insulin levels are unchanged from prior to surgery, it is difficult to assess what cellular changes would occur if the same quantity of insulin was made by the beta cell.
Even moderate weight loss can help reduce diabetes risk.The American Diabetes Association recommends that people at high risk for type 2 diabetes eat high-fiber (14g fiber for every 1,000 calories) and whole-grain foods. A small population of male IRS-2 deficient mice showed hyperglycemia associated with markedly diminished pancreatic islet size, and these extremely hyperglycemic IRS-2 deficient mice exhibited 1) abrupt onset of diabetes and 2) very short duration of diabetic symptoms, such as polyuria, thirst, and body weight loss.
Hellerstrom, (1994, (1994).Cytokines suppress human islet function irrespective of their effects on nitric oxide generation. Thus, it is necessary to develop feasible strategies for adapting the current care model into a context of shared responsibility between the community and the health-team system (Villalpando et al., 2010b). Schauer et al [18] compared the RYGB and gastric sleeve surgical procedures to medical therapy in the STAMPEDE study (Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently).
Because of these discrepant findings, the precise characterization of how RYGB affects hepatic glucose output also requires additional studies.The clinical observation amongst practitioners in bariatric surgery is that in the immediate post-operative period after gastric bypass there is a rapid decrease of fasting glucose levels.
In rodents that have undergone RYGB, there has been a demonstrated increase in pancreatic beta cell area [51], less beta cell apoptosis [52], and increased beta cell proliferation [53].
High intake of fiber, especially from whole grain cereals and breads, can help reduce type 2 diabetes risk.Patients who are diagnosed with diabetes need to be aware of their heart health nutrition and, in particular, controlling high blood pressure and cholesterol levels.


These symptoms resembled the features of human nonautoimmune FT1DM (Hashimoto et al., 2006). Macrophages (but not T cells) infiltration is observed frequently in FT1DM (Shibasaki et al., 2010). In this chapter, we present a community participation model for the prevention and control of diabetes mellitus.
The Roux-en-Y gastric bypass (RYGB) is a type of bariatric surgery that involves the creation of a smaller stomach with a connection to the middle portion of the small intestine, bypassing the duodenum and a portion of the jejunum (see figure 1).
Mingrone et al [19] compared RYGB and biliopancreatic diversion (BPD) procedures to medical therapy. However, dietary caloric restriction alone has been shown to decrease hepatic glucose output without affecting whole body glucose disposal [38-39].
For people who have diabetes, the treatment goals for a diabetes diet are:Achieve near normal blood glucose levels. Characteristics of abrupt onset of hyperglycemia associated with marked diminished islet mass in IRS-2 deficient mice were investigated to analyze the onset mechanism of FT1DM.2. This model establishes as its fundamental strategy the implementation of a formal health-promoters training program so that program participants will achieve empowerment and constitute a social capital of benefit to themselves through active participation in the community with the practice of self-care, mutual aid, and self-promotion in an organized and systematic social network (Mendoza-Nunez et al., 2009a).
Social support networks and healthThe study of social support and its repercussions on the state of health, well-being, and Quality of life (QOL) has experienced significant development dating from the last three decades of the XX Century, above all in some related disciplines, such as preventive medicine, public health, community psychology, social work, anthropology, and sociology. The two studies had similar findings of greater “normalization” of glucose levels in the surgical patients as compared to medical therapy. People who undergo RYGB often have a post-operative decrease in appetite, anatomically imposed caloric restriction, and healing gastrointestinal anastomoses that require smaller nutrient boluses to allow for healing. Infiltrated macrophages may participate in destruction process of pancreatic islets leading to T1DM. Notwithstanding this, self-help groups, as they are now known, arose in the 1930s in the U.S.
One limb, referred to as the alimentary or Roux limb, is where nutrient boluses pass from the stomach pouch. However, there was still greater weight loss in the surgical groups, contributing to the greater glycemic improvement. In caloric restriction, the improvement of the endogenous glucose production (EGP) appears to be due to reduced glycogenolysis [40]. Much may also be learned of how RYGB affects the pancreas by the associated complication known as post-gastric bypass hypoglycemia (reviewed further in”Antidiabetic effect gone too far?
Overweight patients with type 2 diabetes who are not taking medication should aim for a diet that controls both weight and glucose. The ? cell deficit is believed to be due to autoimmune induced ? cell apoptosis mediated by the release of inflammatory cytokines, such as IL-1? and TNF-?, from T lymphocytes and macrophages (Donath et al., 2003). The other limb, which is the bypassed portion of the gastrointestinal tract, is known as the biliopancreatic limb. Schauer et al [18] further demonstrated that the post-operative weight loss appeared to have no correlation with glucose control. This finding is consistent with a study by Isbell et al [30] demonstrating comparable liver improvements (HOMA-IR) between RYGB subjects and calorie restricted subjects. A reasonable weight is usually defined as what is achievable and sustainable, and helps achieve normal blood glucose levels. Cytokine-induced ? cell death preferentially affects newly forming beta cells, which implies that replicating beta cells might be more vulnerable to cytokine destruction. Therefore, the rapid alterations in hepatic metabolism seen immediately following gastric bypass may be from calorie reduction alone and not alterations brought on by the surgery itself.Further molecular studies have supported the notion that RYGB does not induce a weight independent effect on peripheral insulin sensitivity.
Meier et al [54] demonstrated in human subjects who are afflicted with hyperinsulinemic post-gastric bypass hypoglycemia, the pancreatic beta cell area was not increased as compared to obese or even lean control subjects.
Children, pregnant women, and people recovering from illness should be sure to maintain adequate calories for health.Overall Guidelines. Efforts to expand beta cell mass in type 1 diabetes by fostering?? cell replication are likely to fail unless cytokine-induced apoptosis is concurrently suppressed (Meier et al., 2006).
The basic elements of social support networks comprise social capital, which is defined as the potential exchange of opportunities of a social network. Most remarkably, many obese diabetic patients who undergo RYGB are relieved of their anti-diabetic medications in a matter of days. Time-dependent GLUT4 expression in skeletal and adipose cells in rodents after RYGB and weight loss was discussed earlier [35]. They did demonstrate increased beta cell nuclear diameter in those afflicted with post-gastric bypass hypoglycemia compared to BMI-matched controls, suggestive of altered insulin production and secretion. Inflammatory cytokines from corpulent adipocytes appear to participate in destruction of islets ? cells leading to T1DM. On the other hand, in order to understand the determinants of the wellness-sickness of individuals and populations, it is necessary to explore the biological, social, and psychic spaces of humans.
Therefore, social capital depends in large measure on the social contacts possessed by the individual (Burt, 1997). Before discussing the antidiabetic mechanisms behind RYGB, a further discussion of the meaning of diabetes remission will be explored.
Intramuscular lipid content has also been noted to decrease one year following surgery by as much as 44%, which also contributes to enhanced insulin action [41].
One may therefore hypothesize that the decreased weight in response to the elevated insulin levels in RYGB subjects may be the responsible factor that improves glycemic control. Patients should meet with a professional dietitian to plan an individualized diet within the general guidelines that takes into consideration their own health needs.For example, a patient with type 2 diabetes who is overweight and insulin-resistant may need to have a different carbohydrate-protein balance than a thin patient with type 1 diabetes in danger of kidney disease. Fas and Fas ligand expression are lacking and the mechanism of ? cell destruction differs from that in autoimmune T1DM.
In autoimmune T1DM, ? cells are assumed to be destroyed through a long-standing autoimmune process, whereas in FT1DM, ? cells seem to be destroyed very rapidly, probably by a destructive process triggered by viral infection (Hanafusa & Imagawa, 2008). Each of these dimensions constitutes a viewpoint on wellness-sickness and on the factors affecting this.
A seemingly simple concept, we wish to elaborate on the meaning of “diabetes remission,” as well as discuss the associated complexities.
These observations alone suggest why peripheral insulin sensitivity is delayed and appears to be affected only by the presence of adiposity. Despite these studies, further characterization is needed to understand how the pancreas responds to RYGB in T2DM independent of weight loss. Because regulating diabetes is an individual situation, everyone with this condition should get help from a dietary professional in selecting the diet best for them.Several good dietary methods are available to meet the goals described above.
Since IRS-2 deficient mice were maintained under specific pathogen free conditions (Hashimoto et al., 2006), viral infection was deleted from the causes of ? cell destruction. None of these dimensions is independent of the others, nor is any sufficient for summarizing the significance of health and what the determinants of the latter are.
Alteration in gut hormone levels have been strongly implicated as a cause for the metabolic improvement seen in RYGB subjects, but has not clearly been associated with the changes in altered insulin sensitivity. Beta cell dysfunction is considered a hallmark of T2DM, often with hyperinsulinemia and gradual insulinopenia. General dietary guidelines for diabetes recommend:Carbohydrates should provide 45 - 65% of total daily calories. In recent study, macrophages and T cells - but not natural killer cells – had infiltrated the islets and the exocrine pancreas and Toll-like receptor (TLR) 3, a sensor of viral components, was detected in most of macrophages and T cells in FT1DM patients (Shibasaki et al., 2010). Chronic exposure of human islets to leptin leads to ? cell apoptosis (Donath et al., 2003).
This should be assumed by the entire society and depends on the capacity of the State to guarantee access to education, health services, safety, and a healthy environment. Roux-en-Y gastric bypass and remission of type 2 diabetes mellitusMany subjects who undergo RYGB surgery and have T2DM observe a rapid normalization of their glucose levels, leading them to believe they have been “cured” of their diabetes.
The effect of GLP-1 on peripheral tissue has demonstrated some effect on glucose uptake in adipocytes and skeletal muscle cells [42-43].
The altered post-prandial insulin profile seen after RYGB suggests beta cell function has only been altered, and not necessarily restored to appropriate physiologic function.
Their study showed remarkably decreased numbers of pancreatic beta and alpha cells, macrophage-dominated insulitis and the expression of TLRs, a signature of viral infection, in FT1DM soon after the disease onset. TNF?, in combination with other cytokines, accelerates dysfunction and destruction of the ? cell (Eizirik & Mandrup-Poulsen, 2001). In addition, the social control that is exercised by means of regulations, sanctions, or interventions can also exert an influence on attitudes and changes in conduct (Arechabala & Miranda, 2002). Improvement or remission of T2DM was thought to be due to weight loss in obese subjects [3, 5].
While these authors feel the term “cure” is incorrect, we cannot deny, and in fact pleasantly enjoy, watching the marked improvement in hyperglycemia following surgery.
However, the authors feel the effect of GLP-1 has more clinically significant effects on pancreatic function. These results suggest a new mechanism of virus-induced macrophage-dominated inflammatory process, rather than autoimmune T cell response, plays a major role in ? cell destruction in FT1DM. IL-6 released by adipocytes may be responsible for the increases in plasma IL-6 concentrations observed in obesity and at least in combination with other cytokines, IL-6 has cytotoxic effects on ? cell (Eizirik et al., 1994).
The manner of conceptualizing health and disease should evolve so that it is not only the result of consensuses of normality and abnormality, of statistical tables or measurements by techno-scientific apparatuses, but rather, the result of a dialog in which the scientific, subjective, and contextual aspects of biopsychosocial humans participate (Caponi, 1997). Therefore, a suitable social network is considered as an open, multicenter system made up of informal (family, friends, community) and formal components (professional and institutional), with defined objectives and goals framed within a program that, through the empowerment of individuals, achieves maximal health and well-being according to their sociocultural context. This was further supported by studies with gastric banding, a form of enforced caloric restriction [8]. The role of GLP-1 is discussed further in the section “Identifying anti-diabetic factors of gastric bypass.”It is of interest that RYGB and other weight loss surgeries have differential effects on insulin sensitivity and insulin secretion. Identifying anti-diabetic factors of gastric bypassAlterations of insulin secretion itself is a contributing factor that ameliorates the diabetic state in RYGB.
Patients with diabetes should monitor their carbohydrate intake either through carbohydrate counting or meal planning exchange lists.Fats should provide 25 - 35% of daily calories. Increased FFA levels are known to be toxic for ? cell, leading to the concept of lipotoxicity (McGarry & Dobbins, 1999). At present, it is recognized that one of the basic strategies for the prevention and control of diabetes mellitus is the establishment, coordination, and monitoring of social support networks as part of public policy (Mendoza-Nunez et al., 2009b). However, clinicians began to observe that glucose levels were significantly lower in RYGB subjects as compared to weight matched controls [7]. Buse et al had [20] recently defined prolonged diabetes remission as hyperglycemia that is below the diagnostic threshold for diabetes for at least five years, while on no active pharmacologic therapy for diabetes. The biliopancreatic diversion (BPD), a more malabsorptive surgery with a more extensive bypass, is often reserved for the super-obese population.
Monounsaturated (such as olive, peanut, canola oils; and avocados and nuts) and omega-3 polyunsaturated (such as fish, flaxseed oil, and walnuts) fats are the best types. The toxic effect of FFA is mediated via formation of ceramide, increased nitric oxide production and activation of the apoptotic mitochondrial pathway (Maedler et al., 2001).
Social support networks are a potential source of well-being and health, because health can be transmissible and the vehicle is the social support network.6. Although malabsorption also likely contributes to the improved dysglycemia, there are other hormonal changes that are likely contributing to this effect.
The increasing number of diabetes remissions after RYGB surgery has caused practitioners to revisit the definition.Mingrone and Schauer’s studies included similar definitions of diabetes remission in their trials, although their studies were less than five years in duration. However, this surgery been suggested to improve glycemia through normalization of insulin sensitivity [44].
Several investigators have proposed various intestinal mediators that may induce euglycemia, none of which have fully explained the clinical potency of RYGB. To date, viral infection has been the most popular speculated cause of acute destruction of the pancreatic ?cell as many patients reported flu-like symptoms prior to the disease onset (Zheng et al., 2011). Elevated glucose concentrations induced ? cell apoptosis at higher concentration in rodent islet (Efanova et al., 1998). Notwithstanding its transitory situation, the way of looking at health by those wielding power over more or less extensive population groups defines the way of acting in relation to their health and the purposes and forms of utilizing their resources (Chapela, 2008a).In this work, we understand health as “the capacity of the human corporeal nature to decide and contract viable futures and of reaching these”.
This contrasts to RYGB, which we have discussed here, in that it does not appear to rely on insulin sensitivity for rapid improvement of hyperglycemia. Earlier studies suggested that exclusion of the proximal gut was responsible for the improvement of hyperglycemia, implying a potential “diabetogenic factor.” Rubino et al [55] was the first to support this concept, by performing a duodenal-jejunal exclusion in diabetic rodents known as Goto-Kakizaki rodents. In human islets glucose-induced ? cell apoptosis and dysfunction are mediated by ? cell production and secretion of IL-1?.
This definition of health, on the one hand, conceives of the subject as body-subjectivity, that is, as only one thing, and on the other, sets forth a cross-disciplinary and multi-conceptual position on health and ponders the subject in collective fashion (Chapela, 2008a).
Empowerment involves self-strengthening, control, self-power, self-confidence, making decisions of one’s own accord, a fitting life according to one’s values, the capacity to fight for one’s rights, independence, to the right to make one’s own decisions. These are hormones that are secreted by enteroendocrine cells from the stomach, pancreas, and small intestine. We have demonstrated here that peripheral insulin sensitivity improves as a function of weight loss, independent of RYGB, whereas hepatic insulin sensitivity improves as a function of caloric restriction.
This was a surgery that led to preservation of gastric volume, with a pure exclusion of proximal intestinal absorptive surfaces.
Limit trans-fats (such as hydrogenated fat found in snack foods, fried foods, and commercially baked goods) to less than 1% of total calories.Protein should provide 12 - 20% of daily calories, although this may vary depending on a patient’s individual health requirements. Immunohistochemical analyses revealed the presence of enterovirus-capsid protein in all three affected pancreata. This definition allows us to disassociate health from sickness, to understand that the former is an essential part of the subject and not solely a state or a moment in life.
Neural based mechanisms have also been implied as contributors to the glycemic improvement, although much is still not understood.
The initial excitement of his findings surrounded the premise that there was greater glycemic control as compared to calorie restricted rodents, simply by removing a portion of the intestine without creating caloric restriction.
Extensive infiltration of CXCR3 receptor-bearing T-cells and macrophages into islets was observed. IL-1? and ROS activate the transcription factor nuclear transcription factor (NF) ?B, which plays a critical role in mediating inflammatory responses. The latter term shows us that the subject has a great deal to do with the construction of health at the individual as well as at the collective level, without forgetting that the human corporeal-nature capacity of deciding and constructing futures is mediated not only by the individual’s world vision, by history, that is, by past, present, and future happenings that have permeated the person’s being and the individual’s being in the world, but also by the social guidelines that structure the ways that subjects proceed, without forgetting the psychobiological dimension in which aspirations, wishes, sensations, and emotions, and, of course, actions take place, having the political and economic dimensions as a framework (Chapela, 2008a). In this regard, in order to exercise empowerment in an efficient and efficacious manner, it is indispensible to consider four key elements (Narayan, 2002):Access to information.
This is a well accepted phenomenon seen with RYGB subjects, and is believed to contribute significantly to this improvement of hyperglycemia in diabetics.
Born from this procedure was the concept of the “foregut theory.” From this, it was perceived that there was a “diabetogenic factor” in this region of the intestine. To better understand how RYGB affects those with T2DM, we will review the changes that occur with RYGB in key glucoregulatory organ systems within the body. Are the diabetic microvascular complications also reversed and should practitioners stop following these patients if they do go into remission? Effects of gastric bypass surgery on pancreatic functionT2DM is characterized by both peripheral insulin resistance, as well as pancreatic beta cell dysfunction.
However, this concept was later challenged by the “hindgut theory.” The “hindgut theory,” perhaps more popular, operated on the premise that there were factors in the distal intestine that became elevated and had potent anti-diabetogenic effects. Both low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia) are of concern for patients who take insulin. Interferon-? and CXC chemokine ligand 10 (CXCL10) were strongly coexpressed in all subtypes of islet cells, including ?cell and ? cells. Health Promotion (HP)The notion of HP is also complex and controversial, and to date, a consensus has not been reached with regard to its significance. Individuals should be included in decision-making to ensure that the use of public and private resources responds to the real needs of the population. In the ensuing sections, we will discuss in detail, the changes of peripheral insulin sensitivity and insulin secretion brought on by gastric bypass, and their effects on hyperglycemia. If there is complete reversal, why not use the term “cure?” Most important, has the characteristic pancreatic beta cell dysfunction reversed itself?
For this reason, understanding how RYGB affects the pancreas may allow us to better understand why diabetes improves after the surgery.
Laboratory data in IRS-2 deficient mice with FT1DM reveal hyperglycemia, hyperlipidemia and remarkable decrease in insulin secretion as in human FT1DM patients (Table 3).
These are questions proposed by these authors, some of which will be addressed in later sections.
The majority of available studies involve dynamic biochemical measurements involving nutrient challenges.
Further support for this are studies performed with feeding tubes placed in the gastric remnant of the intestine following RYGB. The above symptoms of T1DM were onset abruptly after hyperglycemia was observed in IRS-2 deficient mice. Public servants and those responsible for Non-governmental organizations (NGOs) should respond for their policies, actions, and the use of funds.Local organizational capacity. We will also discuss the role that caloric restriction and gut hormone elevation may have in this process. Despite these questions, it is very hard to ignore the potent clinical effect the surgery has on diabetes.
The impetus for study of these nutrient challenges, such as mixed meal testing, is based on the link between RYGB and postprandial gut hormone hypersecretion [45]. Hansen et al [56] demonstrated that using gastric feeding tubes led to increased gut hormones, as well as via oral (jejunal) routes. Hemoglobin A1C (also called HbA1c or HA1c) is measured periodically every 2 - 3 months, or at least twice a year, to determine the average blood-sugar level over the lifespan of the red blood cell. Expression of MHC class II and hyper-expression of MHC class I was observed in some islet cells. Insulitis with macrophage dominant infiltration was observed in IRS-2 deficient mice and human FT1DM.
According to the Ottawa Charter, HP is a process that permits people to increase control over their health to improve it. The population should possess the ability to organize itself and to work in a group, with the goal of participating actively in the community intervention programs that are developed in its milieu.
For those physicians and health care practitioners who struggle with uncontrolled diabetic patients, it is a seemingly effective and attractive solution.
Exaggerated gut hormone secretion appears to occur because of the altered transit of nutrient boluses caused by the gastric bypass, and is a well accepted phenomenon. The similar alterations in insulin sensitivity between the two nutrient routes suggest the exclusion of nutrients from the foregut is not significant. While fingerprick self-testing provides information on blood glucose for that day, the A1C test shows how well blood sugar has been controlled over the period of several months. These observations strongly suggest the presence of a circuit for destruction of ?cells in FT1DM. It constitutes a political, social, and global progression that encompasses not only actions directed precisely toward strengthening the abilities and capacities of individuals, but one that is also directed toward modifying social, environmental, and economic conditions with the aim of mitigating their impact on public and individual health. Cumulatively, this will permit the reader to develop an understanding of the relationship of how RYGB affects diabetes. The metabolic potency of RYGB has even been addressed by the International Diabetes Federation (IDF) in a statement published in 2011 [21]. Several gut hormones have been suggested to also alter insulin secretion, and are termed “incretins.” The incretin effect relates to the ability of an oral glucose load to result in an enhanced insulin response as compared to a similar intraveous glucose load. Instead, distal gut factors such as GLP-1 may more likely be the cause.GLP-1 physiology will not be covered here in depth. For most people with well-controlled diabetes, A1C levels should be at around 7%.Other Tests.
Enterovirus infection of the pancreata initiates coexpression of interferon-? and CXCL10 in ?cells. Since FT1DM was observed in only male IRS-2 deficient mice, pregnancy is not associated with onset of FT1DM. HP is the process that allows people to increase their control over the determinants of health and, consequently, to improve it. The distal gut hormone GLP-1 has been shown to be primarily responsible for mediating this effect, although other possible contributing anti-diabetic factors have yet to be characterized. Its anti-diabetic effect in gastric bypass has been demonstrated in rodent models that underwent RYGB [57].
Other tests are needed periodically to determine potential complications of diabetes, such as high blood pressure, unhealthy cholesterol levels, and kidney problems. CXCL10 secreted from ?cells activates and attracts autoreactive T-cells and macrophages to the islets via CXCR3. Inflammatory cytokines play a major role in destruction process of pancreatic? cell in both IRS-2 mice and human FT1DM patients.
Participation is essential to sustain action in matters of health promotion (Ottawa Charter for the Promotion of Health, World Health Organization [WHO] Geneva, Switzerland 1986).However, after Ottawa, multiple health promotions may be found in distinct countries and practiced by distinct international organizations, although these affirm that they have adopted the Ottawa Charter as their directorate. Likewise, it has been recognized that education is basic for achieving empowerment (Aujoulat et al., 2007). While a compelling argument can be made for this, we caution practitioners that not all RYGB subjects experience diabetes remission.
There have been surprisingly few studies that have addressed the impact of RYGB on the release of insulin secretion and its relation to other gut hormones. Such tests may also indicate whether current diet plans are helping the patient and whether changes should be made. These infiltrating autoreactive T-cells and macrophages release inflammatory cytokines including interferon-? in the islets, not only damaging ?cells but also accelerating CXCL10 generation in residual ?cells and thus further activating cell-mediated autoimmunity until all ?cells have been destroyed. It has also been cited that social and educational activity in community interventions avoids isolation (Cattan, 2005). There are a small, but significant number of patients that have T2DM and undergo RYGB, but remain hyperglycemic post-operatively.
We will first characterize the pancreatic secretory alterations brought on by the surgery, and then further explain associated hormonal and pancreatic cellular changes.Le Roux CW, Aylwin SJ, Batterham RL et al.
Periodic urine tests for microalbuminuria and blood tests for creatinine can indicate a future risk for serious kidney disease.Other Factors Influencing Diet MaintenanceFood Labels.
On the other hand, Shibasaki et al (2010) investigated pathogenesis of FT1DM with special reference to insulitis and viral infection using pancreatic autopsy samples from three patients.
Insulin resistance by increase in inflammatory cytokines seemed to be main cause to lead ? cell destruction in IRS-2 deficient mice, whereas viral infection may be a trigger for destruction mechanism in human FT1DM patients. The model contemplates a Community United for Human Growth (CUHG), whose purpose is to coordinate the large net of social networks of mutual-aid groups, in which self-care is a daily practice for the prevention and control of diabetes mellitus, as well as for achieving maximal well-being and health as components of one’s human development (Figure 2).
Roux-en-Y Gastric Bypass (RYGB) and its weight independent effect on T2DMSince the early portion of the 21st century, there has been a growing interest in bariatric surgeries and their effect on ameliorating the diabetic state.
In a retrospective review by DiGiorgi et al [22], as much as 24% of T2DM who had undergone RYGB had recurrence of their diabetes over a three year period, while a longer five year study demonstrated 31% recurrence [23]. Gut Hormone Profiles following bariatric surgery favor an anorectic state, facilitate weight loss, and improve metabolic parameters.
Every year thousands of new foods are introduced, many of them advertised as nutritionally beneficial. Both ? and ?cell area were significantly decreased in comparison with those of normal controls. Pories et al was arguably the first to describe remission of diabetes following gastric bypass.
Use of GLP-1 agonists or GLP-1 continuous infusions increased basal insulin secretion, often leading to an improved second phase of insulin secretion [58, 59]. It is important for everyone, most especially people with diabetes, to be able to differentiate advertised claims from truth.
Macrophages and T cells – but not natural killer cells – had infiltrated the islets and the exocrine pancreas. Approximately 50% of the genetic susceptibility can be explained by allele in HLA class II region, in particular certain DQ alleles. He reported gastric bypass not only caused weight loss, it also led to normalization of blood sugars in over 80% of his diabetic patients [9]. Because fasting GLP-1 levels do not increase following surgery, many questions remain regarding its postprandial effects.
Current food labels show the number of calories from fat, the amount of nutrients that are potentially harmful (fat, cholesterol, sodium, and sugars) as well as useful nutrients (fiber, carbohydrates, protein, and vitamins).Labels also show "daily values," the percentage of a daily diet that each of the important nutrients offers in a single serving. More than 95% of type 1 diabetic patients carry these predisposing alleles, but the occurrence of these alleles in the background population is high, approximately 50%. Thus, our proposal establishes the elimination of the stigma of the disease and proposes a model of community intervention for integral human development in which maintenance of health constitutes the key factor. Initially, the normalization of blood sugars was thought to be directly caused by the weight loss. Higher BMI’s, age, prior use of antidiabetic medications, and male gender were identified as factors associated with diabetes recurrence [23, 24]. The majority of studies also demonstrate a postprandial rise of insulin concentration that has a higher and earlier peak than seen pre-operatively [32-34, 46-48]. Perhaps the most important evidence that there are other factors besides GLP-1 in RYGB that contribute to the anti-diabetic effect, is that the pharmacologic use of GLP-1 agonists have not led to the equivalent potency of RYGB surgery alone.
This daily value is based on 2,000 calories, which is often higher than what most patients with diabetes should have, and the serving sizes may not be equivalent to those on diabetic exchange lists. It is believed that the diabetes predisposing DQ antigens have a shape of the antigen presenting groove of the molecule that leads to more efficient presentation of ? cell associated autoantigens (Donath et al., 2003). This model avoids the social prejudices that label “groups of diabetics as sick people who do not follow the rules”, which generates social rejection and abandonment of the group in many participants, who “seek at all times the cure for their incurable disease” in order to “stop being part of the group of diabetics”. However, it has subsequently been noted that blood glucose control improves immediately following the surgery, prior to any significant weight loss.
A similar study in Chinese subjects demonstrated that diabetes duration, BMI, and fasting C-peptide were predictors for diabetes remission at one year.
While this suggests a possible restoration of the first phase of insulin secretion, this remains unclear. Most people will need to recalculate the grams and calories listed on food labels to fit their own serving sizes and calorie needs.Weighing and Measuring.
Enterovirus RNA was detected in ?cells positive islets in one of the three patients by in situ hybridization. In 1996, our research group proposed a community care model, considering the active participation of the individual in order to achieve maximum QOL in their social milieu (Mendoza-Nunez et al., 1996). The concept that weight loss alone was not the reason for diabetes improvement after RYGB was a paradigm shift in the world of weight loss surgery, as well as the world of diabetes.
Weighing and measuring food is extremely important to get the correct number of daily calories.Along with measuring cups and spoons, choose a food scale that measures grams.
In FT1DM patients, the haplotype frequency of HLA DRB1*0901-DQB1*0303 was significantly higher than those in controls (Moreau et al., 2008). In this respect, although the results have been satisfactory, we adapted the model in 2004 according to the paradigm of active aging and subsequently submitted this to a process of investigation to determine its feasibility and pertinence (Martinez-Maldonado et al., 2007). These investigators were the first to suggest predictors and possible cutoffs in assessing the glycemic responses to RYGB. The insulin peak also does not appear to be as marked as the postprandial GLP-1 elevations. Roux-en-Y gastric bypass, satiety, and the central nervous systemThe importance in assessment of decreased caloric intake with diabetes remission has already been discussed, in particular those that undergo gastric banding [8]. HLA phenotyping of these Caucasian patients did not find the specific HLA haplotype (DRB1*0405-DQB1*0401) found to be linked to FT1D in Japanese patients.
As previously mentioned, our proposal is not limited to older adults, because the principles and strategies can be applied to adult population in general.The model establishes as the key element the formation of promoters of integral human development. Determining how to use RYGB in diabetes management is still in the early stages of development. The insulin peak is typically followed by a rapid decrease of insulin and glucose levels following the peak.
Similarly, the RYGB involves creation of a small stomach size, causing similar restriction.
However if it occurs, the rapid onset is associated with an extremely high risk of fetal death. More investigation about haplotype frequency of MHC was necessary for IRS-2 mice in the destruction process of pancreatic ? cells.6. In this regard, promoters function as mutual aid-group coordinators, establishing self-care and self-management actions for their members’ well-being and social development, in which health maintenance is fundamental. It is remarkable that subjects that undergo RYGB actually appear to have a markedly decreased appetite as compared to their gastric band counterparts. Therefore, it is important for physicians to make an appropriate diagnosis as early as possible and to begin immediate treatment of both the mother and the fetus (Murabayashi et al., 2009). ConclusionIRS-2 mice tend to become obese accompanying insulin resistance after 8 weeks of age. However, the insulin area under the curve (AUC), based on these prior studies, is either unchanged or decreased as compared to pre-operative measurements. Because postprandial elevation of gut hormones is a distinguishing factor of RYGB from gastric banding, investigation of their orexogenic and anorexogenic tendencies have recently begun to be characterized. IRS-2 deficient mice develop diabetes, presumably due to inadequate ? cell proliferation combined with insulin resistance compared to IRS-1 deficient mice with the ? cell hyperplasia to compensate for the insulin resistance. Figure 4 demonstrates an example of post-prandial insulin levels in subjects that underwent gastric band and RYGB, as compared to control obese and lean subjects.
Earlier prospective studies generally demonstrated RYGB induced altered satiety [45, 60-62], although the field appears to be lacking trials that are appropriately controlled.The evidence continues to mount for this gut brain communication effect, with several biochemical mechanisms that affect neural signaling of hunger and satiety being discovered.
Heterotopic accumulation of lipid observed frequently in obese IRS-2 mice, and corpulent adipocytes secrete various inflammatory cytokines, such as TNF-? and ILs, whereas production of adiponectin as antidiabetic agent is decreased significantly.
The SOS trial is one of the largest prospective data collections to date that studies the clinical effects of various types of bariatric surgery.
Since 1991, the National Institutes of Health used both BMI and the presence of obesity-related comorbidities as the criteria for surgical weight loss. The control obese subjects were matched to the pre-operative BMI of the surgical patients, and the subjects that underwent either operation had an equivalent post-operative BMI. Therefore, RYGB has effects on satiety that are independent of the physical limitations imposed by the formation of the gastric pouch. People with early-stage kidney failure need to follow a special diet that slows the build-up of wastes in the bloodstream.
A group of patients with PF was compared with a group of patients of child-bearing age with FT1DM that was not associated with pregnancy (NPF) in a nationwide survey conducted from 2000-2004.
The SOS data demonstrates durable weight loss by as much 25% reduction at 10 years with various surgery types. Here, RYGB subjects exhibit the largest post-prandial insulin peak as compared to the gastric band and the remaining non-surgical subjects. The effect gut hormones have on the neural circuitry are most studied specifically within the hypothalamus [63], with the balance of orexogenic and anorexogenic hormones.
The greatest weight loss is observed with RYGB [6] as compared to gastric banding, and a modified restrictive surgery known as vertical banded gastroplasty, (see figure 3).
Prime hormonal candidates for these changes include insulin, leptin, GLP-1, peptide YY (PYY), and ghrelin [61-62, 64-65]. Fat and carbohydrate intake may need to be increased to help maintain weight and muscle tissue.People who have late-stage kidney disease usually need dialysis.
In IRS-2 deficient mice with FT1DM, insulitis with macrophage dominated infiltration to islet ? cell area was observed frequently as in human FT1DM patients. Therefore, any community program directed toward human development in which maintenance of health and improving QOL are considered should establish the mechanisms that allow for its harmonic and complementary execution.
Since SOS, additional studies of obese subjects that have undergone RYGB have verified that weight loss from the surgery is durable and long lasting [10, 11]. We have already pointed out that post-operative weight loss does not always seem to correlate with glycemic control [18].
Decreased insulin levels following RYGB was generally believed to be the case with the perceived notion that insulin sensitivity was improved.
While findings with ghrelin have been mixed, there is growing evidence that the other aforementioned hormones may play a significant role. In 22 PF patients, 18 developed disease during pregnancy, whereas four cases occurred immediately after delivery. Inflammatory cytokines appear to have important roles in the process of ? cell destruction leading to FT1DM. While durability of the surgery continues to be validated in ongoing trials, its weight independent effect on diabetes was initially uncertain during the infancy of bariatric surgery.
However, as mounting evidence shows that peripheral insulin sensitivity is not immediately improved, these alterations in insulin secretion may hold more significance. Patients must still be very careful about restricting salt, potassium, phosphorus, and fluids.
Twelve cases that developed during pregnancy resulted in stillbirty, and five of the six fetal cases that survived were delivered by cesarean section. IRS-2 deficient mice are considered to be useful animal model for studying the mechanism of ? cell destruction leading to FT1DM.
Similarly, mutual aid includes the reasoned and requisite behavior that a group of individuals who share similar problems and who are aware of the advantages and commitments acquired adopts on voluntarily accepting to be part of the group. This uncertainty was at least partially due to the absence of appropriate “control groups” in various studies. Potential changes in alpha cell secretion of glucagon was then investigated to see if that had a possible role in these glycemic changes, namely if levels were decreased.
Origins of these mediators come from multiple different organ systems, which subsequently affect neurons within the arcuate nucleus and other hypothalamic regions. Patients on peritoneal dialysis may have fewer restrictions on salt, potassium, and phosphorus than those on hemodialysis.Major Food ComponentsCarbohydratesCompared to fats and protein, carbohydrates have the greatest impact on blood sugar (glucose). The haplotype frequency of HLA DRB1*0901-DQB1*0303 in PF was significantly higher than those in NPF and controls, whereas that of DRB1*0405-DQB1*0401 in NPF was significantly higher than those in PF.
With regard to self-management, this involves the actions that an individual or self-help group performs in an autonomous manner, in an expected and optimal way, taking into consideration the elements and mechanisms of formal and informal social support networks.
For instance, the SOS data demonstrated reduced incidence of diabetes in surgically treated groups, but this was compared to non-standardized medically treated groups [12]. Seeing such high rates of diabetes remission in a lower BMI range reinforces the concept of weight-independent effects of surgery on diabetes. Except for dietary fiber, which is not digestible, carbohydrates are eventually broken down by the body into glucose.
The type 1 diabetes-susceptible HLA class II haplotype is distinct in PF and NPF patients, suggesting that different HLA haplotypes underlie the presentation of PF or NPF. The CUHG is one of the elements of the social support network, responsible for training Human Development Promoters (HDP), who are in turn responsible for coordinating mutual-aid groups denominated Human Development Nuclei (HDN), which are made up of 10 to 15 adults groups according to their affinities and the geographical closeness to their domiciles.
Medical weight loss therapy can be difficult to implement effectively, and therefore, comparison to surgical subjects is often imbalanced. As most obese individuals fall within this BMI range, clinicians may even consider recommending surgery at an earlier BMI.
Why hyperglucagonemia would be present during the glycemic improvement seen after RYGB is unclear, and needs further studies to validate these findings.Based on the postprandial insulin concentration profile demonstrated in figure 4, the glycemic effects do not clearly show why there would be an improvement of hyperglycemia.
Research into these anti-obesity mechanisms for pharmacologic uses are still being investigated. Carbohydrate types are either complex (as in starches) or simple (as in fruits and sugars).One gram of carbohydrates provides 4 calories. Increasing evidence shows that BMI alone is not an adequate measure to predict successful health outcomes after RYGB.
Available studies do not demonstrate consistently how postprandial glucose levels behave in response to these insulin secretory changes. The current general recommendation is that carbohydrates should provide between 45 - 65% of the daily caloric intake. For this, self-care programs should be implemented for the healthy and sick individual, with pre-established evaluation, surveillance, and primary care-action protocols. Some have demonstrated significantly elevated postprandial glucose levels with a subsequent decrease [32], while others mostly show the postprandial decrease [8].
Roux-en-Y gastric bypass, type 2 diabetes mellitus, and the central nervous systemAutonomic nerve regulation has often been the target for pharmacologic weight loss therapy. HLA phenotyping of these Caucasian patients did not find the specific HLA haplotype (DRB1*0405-DQB1*0401) found to be linked to FT1DM in Japanese patients. We have mentioned that assessing for adequate beta cell function [25] could be used as criteria for successful diabetes remission.
Inconsistency may have to do with varying nutritional content of test meals and timing after the surgery.
Therefore, there has been renewed interest in the role of the vagus nerve within bariatric surgical procedures to determine its role in weight loss. They are more likely to provide other nutritional components and fiber.Vegetables, fruits, whole grains, and beans are good sources of carbohydrates. Thus, we recommend the implantation of programs of recreation, adaptation, and psychosocial and occupational self-improvement under an anthropological focus, according to the individual’s interests, age, schooling, gender, health state, socioeconomic situation, etc. Additional evidence has suggested that those who have most benefited from surgery have elevated insulin levels, or insulin resistance [28, 29]. Using other methods in assessment of glycemic changes with RYGB, continuous glucose monitoring (CGM) has revealed unusual patterns.


Whole grain foods provide more nutritional value than pasta, white bread, and white potatoes. More international collaborative epidemiological studies are warranted in order to better understand and characterize FT1DM associated with pregnancy.3. The model establishes flexible general guidelines that could be adopted for rural and urban population, as well as for groups of adults of different sociocultural and economic conditions. The simultaneous improved cardiovascular effects observed from the surgery [28] may also highlight the intrinsic relationship between insulin resistance and cardiovascular disease, often referred to as the metabolic syndrome. In a group of RYGB subjects, CGM revealed increased glycemic variability using a calculation parameter known as “mean amplitude of glycemic excursions” (MAGE) [49]. An intact vagus nerve with RYGB appears to have a significant and improved effect on food intake and weight loss [70]. As an integral part of the model, the implementation has been established of a “Healthy Life” Program in which, under a constructivist focus, participants establish the strategies for adopting healthy lifestyles, utilizing a self-efficacy instrument to maintain and strengthen behavioral changes. As clinicians and scientists, it is critical for us to evaluate the effects of RYGB surgery beyond simple weight loss. However, the beneficial effect appears to carry over to improved glucose metabolism that also appears to be weight independent. IRS-2 deficient mouseInsulin receptor substrate (IRS) disorders are associated with onset of insulin resistance and diabetes mellitus.
Obese and diabetic rodent models studies have demonstrated that hepatic vagotomy will worsen glucose metabolism [71-72]. Model viabilityThe model has been implemented in Mexico with an older adult population from rural and urban areas. In the remaining portion of this chapter we will characterize the basic driving forces for T2DM and how the surgery brings about an improved glucose effect. This further highlights the necessary role of the vagus for helping attain euglycemia via hepatic-mediated mechanisms. You can limit your fructose intake by consuming fruits that are relatively lower in fructose (cantaloupe, grapefruit, strawberries, peaches, bananas) and avoiding added sugars such as those in sugar-sweetened beverages. IRS-2 deficient mice develop diabetes, presumably due to inadequate ? cell proliferation combined with insulin resistance, and the insulin resistance in IRS-2 deficient mice is ameliorated by reduction of adiposity. This is not without some conflicting studies such as by Shin et al [73], although their focus was on food intake, body weight, and energy expenditure.
Fructose is metabolized differently than other sugars and can significantly raise triglycerides.
IRS-2 deficient mice are widely used for analysis of pathophysiology of human type 2 diabetes mellitus (T2DM). On the other hand, the anthropological aspects associated with the disease should be considered in community interventions, because cultural aspects determine negative lifestyles (sedentary life style and inadequate nutrition), which raises the risk of diabetes mellitus (Martorell, 2005).For this reason, the purpose of our model is the conformation and integration of a “great network of networks” of mutual-aid groups who practice scientifically founded principles of daily self-care and self-management for their human development. In this light, the prevention of chronic diseases, and especially diabetes mellitus, constitutes one of the basic objectives. Effects of gastric bypass surgery on insulin resistanceInsulin action has a key role in regulating glucose homeostasis, facilitating glucose uptake in various tissue types. The source of this neuroendocrine regulation may suggest that hepatic glucose metabolism is uniquely regulated by a hypothalamic source.Pocai A et al [74] demonstrated that activation of potassium-ATP channels within the hypothalamus appears to lower blood glucose through hepatic gluconeogenesis.
These include terms such as sweeteners, syrups, fruit juice concentrates, molasses, and sugar molecules ending in “ose” (like dextrose and sucrose). The symptoms observed in IRS-2 deficient mice with serious T1DM with insulin-deficient hyperglycemia resembled those of human nonautoimmune FT1DM reported by Imagawa et al. Its inability to cause glucose uptake is believed to be a key step in the pathogenesis of T2DM. This was a significant advance in better understanding the mechanisms that may mediate hepatic gluconeogenesis. Healthy lifestyles and diabetes mellitusHealthy lifestyles constitute key elements for preventing and controling DM. Similarly, insulin presence near the hypothalamus has also been demonstrated to suppress lipolysis [75], which directly affects insulin resistance and T2DM.
Additional characterization of the hypothalamic and vagal mediated effects may also help us to better understand the role of the nervous system in glucose and lipid regulation.
It is based on two premises:All carbohydrates (either from sugars or starches) will raise blood sugar to a similar degree, although the rate at which blood sugar rises depends on the type of carbohydrate. Glucose transport is maintained primarily through insulin-regulated glucose transporters, such as GLUT4. In general, 1 gram of carbohydrates raises blood sugar by 3 points in people who weigh 200 pounds, 4 points for people who weigh 150 pounds, and 5 points for 100 pounds.Carbohydrates have the greatest impact on blood sugar. At 6 week of age, there was no difference in body weight between wild-type (control) and IRS-2 deficient mice, but IRS-2 deficient mice showed remarkable impaired glucose tolerance and insulin resistance (Hashimoto et al., 2006). Among the factors linked with compliance with healthy lifestyles, we are able to highlight self-efficacy and self-esteem. Commonly proposed theories that may mediate insulin resistance include impaired insulin signaling defects, GLUT transporter dysfunction, as well as increased availability of circulating free fatty acids. PYY) may not only have anorexogenic effects that modify caloric intake, but they may also directly mediate glucose regulation via central nervous system mechanisms.
Fats and protein play only minor roles.In other words, the amount of carbohydrates eaten (rather than fats or proteins) will determine how high blood sugar levels will rise. IRS-2 deficient mice showed significant increases in plasma glucose, free fatty acid (FFA), triglyceride (TG), total cholesterol (TC) and insulin concentrations compared to wild-type (control) mice at 6-week-old.
Both environmental and molecular factors may contribute to the development of insulin resistance. Further identification of where gut hormone receptors exist are needed to better understand this potentially significant glucose-governing mechanism. In the livers of male IRS-2 deficient mice, the activities of cytosolic pyruvate kinase (PK), glucose-6-phosphate dehydrogenase (G6PD), ATP citrate lyase (ACL), fatty acid synthase (FAS) and malic enzyme (ME) were significantly higher than those of control mice (Table 1).
Obesity, as an environmental source, is believed to be a very common contributor.Insulin resistance has been significantly observed at the level of the liver, skeletal muscle, adipose tissue, and pancreas. Increase in activities of G6PD, ACL, FAS and ME, which are crucial enzymes for fatty acid synthesis, means activation of lipid synthesis in liver of IRS-2 deficient mice.
Nonetheless, it is important to cite that these recommendations should be adapted to age, gender, occupation, health state, socioeconomic level, food preferences, and food availability. But it is skeletal muscle and adipose tissue that account for over 80% of total body glucose uptake.
Once the patient learns how to count carbohydrates and adjust insulin doses to their meals, many find it more flexible, more accurate in predicting blood sugar increases, and easier to plan meals than other systems.The basic goal is to balance insulin with the amount of carbohydrates eaten in order to control blood glucose levels after a meal. Because the reversal of diabetes immediately following gastric bypass is so profound, an alteration of peripheral tissue insulin sensitivity was thought to be the mechanism for achieving normoglycemia.
Postgastric bypass hypoglycemiaPerhaps best described by the title of the article by Patti ME et al “Hypoglycemia following gastric bypass surgery-diabetes remission in the extreme?”[76] the condition of post-gastric bypass hypoglycemia has been an increasingly observed phenomenon.
On the other hand, two of eight male IRS-2 deficient mice each at the ages of 14 and 24 week suddenly showed extreme hyperglycemia, similar to that in case of FT1DM. With RYGB having superior weight loss, it has been well accepted that improved insulin sensitivity in surgical patients is also superior. Contrasting mechanisms of how this occurs have been proposed, with the initial reports suggesting islet cell hyperplasia [77]. Another 2 male IRS-2 deficient mice developed extreme hyperglycemia at the age of 11 and 12 week and died. ConclusionThe proposed model of community participation for the prevention and control of diabetes mellitus establishes as fundamental elements a broad concept of health, the concepts of citizenship and empowerment, and as self-care strategies, mutual aid and self-management with the support of social networks. However, the timing of when peripheral insulin sensitivity improves has been an area of uncertainty. However, follow up studies suggested there was no change in beta cell mass, although there was an increase in beta cell nuclear diameter [54]. Plasma glucose and FFA concentrations in the extremely hyperglycemic IRS-2 deficient mice showed abnormal increases compared with moderately hyperglycemic IRS-2 deficient mice. Answering when peripheral insulin sensitivity begins after RYGB will also help to elucidate if it is a weight independent event.The most frequently used measure of insulin resistance is the Homeostasis Model Assessment Insulin-Resistance (HOMA-IR). The increase in beta cell diameter may be more of a function of increased nuclear transcriptional activity of insulin production. This ratio determines the number of carbohydrate grams that a patient needs to cover the daily pre-meal insulin needs.
Plasma insulin concentrations in extremely hyperglycemic IRS-2 deficient mice were below the detection limit. The ease of obtaining measurable glucose parameters have made this a popular method for quantifying insulin sensitivity.
This would coincide with those afflicted with this condition may have hypersecretion of insulin.
Eventually, patients can learn to adjust their insulin doses to their meals.Patients who choose this approach must still be aware of protein and fat content in foods.
On histopathologic examination, the pancreatic islets of extremely hyperglycemic IRS-2 deficient mice were either absent or decreased in size and number compared with those of moderately hyperglycemic IRS-2 deficient mice. This model represents important savings of economic resources for the State.Finally, to strengthen the viability of the model, it is indispensable that the State establish public policies that permit the development of this type of model. Several sources cite RYGB improves HOMA-IR from four days to two weeks following surgery in diabetic and non-diabetic subjects [30-31]. Hypersecretion of insulin at disproportionate levels to the decreased BMI following surgery may potentially lead to clinically significant hypoglycemia.
The islets of extremely hyperglycemic IRS-2 deficient mice showed karyorrhexis, cytoplasmic swelling, and partial necrosis.
In addition, the liver of one extremely hyperglycemic IRS-2 deficient mouse showed collagen fibrinoid degeneration and macrophages.In conclusion, at 6 week of age, IRS-2 deficient mice showed profiles compatible with several features of metabolic syndrome, including hyperglycemia, hyperinsulinemia, insulin resistance, hypertriglyceridemia, and high FFA concentrations. In a non-weight controlled study, HOMA-IR was also decreased at three days following surgery [32].
If we recall the changes in peak of insulin secretion discussed earlier brought on by RYGB [32-34, 46-48], a comparison to BMI-matched subjects afflicted with hypoglycemia demonstrated a greater post prandial peak of insulin secretion [78].
The glycemic index helps determine which carbohydrate-containing foods raise blood glucose levels more or less quickly after a meal.
However, these same sources demonstrate that HOMA-IR in RYGB subjects has comparable improvement to that of diet controlled subjects at similar time intervals while on calorie restriction [30-31].
This may lead to increased glycemic variability, which has been demonstrated in subjects who are afflicted with post-gastric bypass hypoglycemia [40].
The index uses a set of numbers for specific foods that reflect greatest to least delay in producing an increase in blood sugar after a meal. Moreover, hyperglycemia and insulin resistance in these mice progressed to their highest levels when the animals were 14 week of age. While this is suggestive that RYGB may induce hypoglycemia via pancreatic mediated mechanisms, the question of the contribution of peripheral insulin sensitivity to hypoglycemia was answered by Kim et al [79]. The lower the index number, the better the impact on glucose levels.There are two indices in use. A small population of male IRS-2 deficient mice developed abrupt onset of hyperglycemia associated with markedly diminished islet mass, resembling the features of human nonautoimmune FT1DM.
These findings are suggestive that immediate changes in HOMA-IR following RYGB are possibly related to caloric restriction alone. Using intravenous glucose infusions in BMI matched controls, Kim et al [80] showed that those who are afflicted with hypoglycemia demonstrated appropriate insulin secretion rates in response to intravenous glucose challenges. One uses a scale of 1 - 100 with 100 representing a glucose tablet, which has the most rapid effect on blood sugar. Therefore, it appears the hypoglycemia is only brought on by ingestion of nutrient boluses which elicits an abnormal insulin response.
While the response may be effective in mediating improved glucose control, it is unclear why some subjects develop hypoglycemia and others do not. Obesity with insulin resistance in IRS-2 deficient mice with high-fat diet feedingType 2 diabetes mellitus (T2DM) appears to be increasing mainly in the United States, Africa and Asia. Possible causes may have to do with prior history of diabetes and residual insulin resistance. Substituting low- for high-glycemic index foods may also help with weight control.One easy way to improve glycemic index is to simply replace starches and sugars with whole grains and legumes (dried peas, beans, and lentils). In 2000 there were one hundred and fifty million T2DM patients, but they are predicted to increase substantially to two hundred and twenty million world-wide in 2010. Because of the increasing number of bariatric surgeries being performed, this is an area that is in urgent need of further study. However, there are many factors that affect the glycemic index of foods, and maintaining a diet with low glycemic load is not straightforward.No one should use the glycemic index as a complete dietary guide, since it does not provide nutritional guidelines for all foods. Since World War II (WWII), T2DM patients have increased markedly with dramatic changes of lifestyle in Japan. Understanding how this condition develops will also likely shed light on how the surgery helps improve hyperglycemia. It is simply an indication of how the metabolism will respond to certain carbohydrates.Low-Carbohydrate Diets. Typical changes of the lifestyle include the increases in high fat diets, sedentary habit and driving. Currently, our laboratory is involved with ongoing clinical trials to better understand the mechanisms behind this clinically significant phenomena.
Low carb diets generally restrict the amount of carbohydrates but do not restrict protein sources.
Popular low-carb diet plans include Atkins, South Beach, The Zone, and Sugar Busters.The Atkins diet restricts complex carbohydrates in vegetables and fruits that are known to protect against heart disease. Japanese population is predisposed to develop T2DM due to insufficient insulin secretion in spite of no predisposition to obesity. The Atkins diet also can cause excessive calcium excretion in urine, which increases the risk for kidney stones and osteoporosis.Low-carb diets such as South Beach, The Zone, and Sugar Busters rely on the glycemic index. IRS-2 deficient mice show at 6 weeks of age showed profiles compatible with several features of the metabolic syndrome, including hyperglycemia, hyperinsulinemia, insulin resistance, hypertriglyceridemia, and high FFA. To investigate the characteristics in energy metabolism in IRS-2 deficient, three kinds of diets with different lipid concentrations were supplied to IRS-2 deficient mice (4 weeks old) for 2weeks. The growing popularity of the bariatric weight loss surgery known as the sleeve gastrectomy is worthy of discussion. The procedure involves the removal of the antrum of the stomach, with a creation of a sleeve-like structure. The potency of the sleeve gastrectomy on diabetes has been demonstrated by Schauer et al [18]. Foods high on the glycemic index include bread, white potatoes, and pasta while low-glycemic foods include whole grains, fruit, lentils, and soybeans.The Mediterranean Diet is a heart-healthy diet that is rich in vegetables, fruits, and whole grains as well as healthy monounsaturated fats such as olive oil. While the improvement of hemoglobin A1c reduction was greater in those that underwent RYGB, the sleeve gastrectomy had a similar reduction of almost 3% at one year following surgery. In studies of patients with type 2 diabetes, a low-carb version of the diet (restricting carbohydrates to less than 50% of total calories) worked better than a low-fat diet in promoting weight loss, reducing A1C levels, and improving insulin sensitivity and glycemic control.According to the American Diabetes Association (ADA), low-carb diets may help reduce weight in the short term (up to 1 year). The question remains if there is a weight-independent effect of diabetes improvement with this surgery?Earlier prospective studies of the sleeve gastrectomy, as compared to the RYGB, demonstrated that weight loss and glucose homeostasis was also similarly improved between the two [80-81]. However, because these diets tend to include more fat and protein, the ADA recommends that people on these diet plans have their blood lipids, including cholesterol and triglycerides, regularly monitored. Japanese and American diet increased significantly the body weight of IRS-2 deficient mice when compared with regular diet. However, they also demonstrated increased postprandial elevation of GLP-1, PYY, and insulin levels, although generally slightly less than RYGB.
Patients who have kidney problems need to be careful about protein consumption, as high-protein diets can worsen this condition.Whole Grains, Nuts, and Fiber-Rich FoodsFiber is an important component of many complex carbohydrates. Ad group showed severely impaired glucose tolerance, and Jd and Ad group showed deterioration of insulin resistance. Short term (6 weeks) and long term (1 year) follow up demonstrated comparable GLP-1 responses to mixed meal challenges [82-83]. It is found only in plant foods such as vegetables, fruits, whole grains, nuts, and legumes (dried beans, peanuts, and peas). The alterations of GLP-1 and PYY secretion is confusing and remains not well explained within the literature.
RYGB has been associated with earlier transit of nutrients to the distal intestine, stimulating an elevation of the “hindgut hormones.” These elevations may potentially explain the glycemic improvement. Instead, it passes through the intestines, drawing water with it, and is eliminated as part of feces content. However, these observations do not explain why the postprandial hormone elevation with the sleeve gastrectomy occurs. The following are specific advantages from high-fiber diets (up to 50 grams a day):Insoluble fiber (found in wheat bran, whole grains, seeds, nuts, legumes, and fruit and vegetable peels) may help achieve weight loss. The literature still lacks a satisfactory mechanism of the stimulating mechanism for these elevations.
Consuming whole grains on a regular basis appears to provide many important benefits, especially for people with type 2 diabetes. Figure 1 shows expression of mRNA in WAT and plasma cytokine concentrations in IRS-2 deficient mice.
However, the clinical effects of the sleeve gastrectomy on diabetes remains difficult to ignore. Of special note, nuts (such as almonds, macadamia, and walnuts) may be highly heart protective, independent of their fiber content. The mechanism remains elusive, and many questions remain about the effects of the sleeve gastrectomy.
Fat substitutes added to commercial foods or used in baking, deliver some of the desirable qualities of fat but do not add as many calories. The lack of an intestinal bypass prevents associated malabsorption and the plethora of micronutrient deficiencies.
MRI showed the effects of Japanese and American diets on intraperitoneal WAT in IRS-2 deficient mice.
Fat substitutes include:Plant substances known as sterols, and their derivatives called stanols, reduce cholesterol by blocking its absorption in the intestinal tract.
Despite these appealing features, we would advise practitioners to evaluate their patients carefully when considering a bariatric surgical method for weight loss. Margarines containing sterols are available.Olestra (Olean) passes through the body without leaving behind any calories from fat. WAT around the kidney and testes in the Jd and Ad groups increased in proportion to fat concentrations of diets when compared with the Rd group. Little to no long-term studies are currently available on their clinical potency, and the lack of understanding how the surgery affects diabetes should give practitioners pause. However, it can cause cramps and diarrhea, and even small amounts of olestra may prevent the body from absorbing certain vitamins and nutrients.Artificial Sweeteners. In addition, adipocytes of the Jd and Ad groups were corpulent when compared with those of the Rd group (Figure 2c). However, the surgery is still very promising with apparently little metabolic complications. The authors are excited about the growing role of the sleeve gastrectomy in weight loss procedures.6. ConclusionRYGB unquestionably ameliorates the hyperglycemic state in many of those with T2DM.
On histopathologic examination of islets, insulin secretion was observed in all three groups.In conclusion, high-fat diet feeding induced rapid accumulation of fat intraperitoneal cavity of IRS-2 deficient mice. Many who undergo the surgery gain significant health benefits, and achieve remission of their diabetes.
Aspartame is generally considered safe, but people with phenylketonuria (PKU), a rare genetic condition, should not use it.Saccharin (Sweet'N Low). Obese IRS-2 deficient mice showed higher activities of lipid synthesis in their livers and the increase in TNF-? of corpulent adipocyte origin further aggravated insulin resistance and the increase in resistin also aggravated the impaired glucose tolerance, leading to aggravation of T2DM. Investigators are attempting to understand the clinical impact of diabetes remission on RYGB patients, as well as the mechanism of how this is achieved.
Plasma adiponectin concentrations decreased significantly in obese IRS-2 deficient mice fed on high-fat diet, and decreased adiponectin concentrations might worsen T2DM to severe diabetic condition.4.
The improvement of peripheral insulin sensitivity appears to be weight dependent, while hepatic insulin sensitivity seems to be a function of caloric restriction.
Although early studies in rats indicated a potential risk for cancer, subsequent research has shown that saccharin does not cause cancer.Sucralose (Splenda). However, alterations in pancreatic function are reflected in the robust postprandial insulin secretion profile, and appear to be a direct result of RYGB. Sucralose has no bitter aftertaste and works well in baking, unlike other artificial sweeteners.
Onset of FT1DM in IRS-2 deficient miceTwo of eight male IRS-2 deficient mice each at 14 and 24 weeks of age suddenly showed extreme hyperglycemia associated with markedly diminished pancreatic islet size. Understanding the condition of the pancreas’ endogenous insulin producing ability and the whole body insulin resistance may allow us to predict who will achieve diabetic remission.The increasing clinical phenomenon of post-gastric bypass hypoglycemia may be a result of an undesired overenhancement of the alterations brought on by surgery.
It is made from real sugar by replacing hydroxyl atoms with chlorine atoms.Rebiana (Truvia, PureVia) is an extract derived from stevia, a South American plant. These extremely hyperglycemic mice had greatly diminished activities of hepatic ACL, FAS, and ME.
This condition needs further study to better aide those afflicted with this potentially debilitating condition. In these mice, plasma ALT activities were elevated and histochemical analysis of the liver confirmed inflammation. As a possible alternative, the sleeve gastrectomy may potentially be an alternative weight loss surgery that appears to have lesser metabolic complications than are associated with RYGB. These cases of extreme diabetes resemble the human nonautoimmune FT1DM (Hashimoto et al., 2006). However, understanding of how it mediates its effect on diabetes is still not understood, and also is in great need of additional research.7.
Occurrence rate of FT1D appears to be ~20% in male IRS-2 deficient mice after the age of 8 weeks, and is not observed in the female mice. It is only used as a general-purpose sweetener in commercial food products such as baked goods and soft drinks.Sugar alcohols (which include xylitol, mannitol, and sorbitol) are often used in “sugar-free” products, such as cookies, hard candies, and chewing gum.
Characteristics of plasma metabolite and hormones in IRS-2 deficient mice with FT1DMBecause over 50% of male IRS-2 deficient mice after 10 weeks of age tended to show glycosuria with obesity, male IRS-2 deficient mice (8 weeks old) without glycosuria according to Diasticks (Bayer Medical Ltd., Tokyo, Japan) were used as the control. The American Diabetes Association recommends against consuming large amounts of sugar alcohol as it can cause gas and diarrhea, especially in children.ProteinProtein intake in diabetes is complicated and depends on various factors. Plasma glucose, FFA, TG, TC, insulin and C-peptide concentrations and hepatic enzyme activities were compared between control and diabetic mice. There are additional guidelines for patients who show signs of kidney damage (diabetic nephropathy).In general, diabetes dietary guidelines recommend that proteins should provide 12 - 20% of total daily calories. As the diabetic mice (8-24 weeks old) were older than the control mice (8 weeks old), the reduction of body weights in the diabetic mice was significant. Some doctors recommend a higher proportion of protein (20 - 30%) for patients with pre- or type 2 diabetes. In the diabetic mice, the plasma glucose and TC concentrations were significantly higher than those in the controls, whereas plasma insulin and C-peptide concentrations decreased significantly under one third of the control values.
They think that eating more protein helps people feel more full and thus reduces overall calories.
In addition, protein consumption helps the body maintain lean body mass during weight loss.Patients with diabetic kidney problems need to limit their intake of protein.
A typical protein-restricted diet limits protein intake to no more than 10% of total daily calories. Patients with kidney damage also need to limit their intake of phosphorus, a mineral found in dairy products, beans, and nuts. Existence of the islet-related antibodies was investigated immunohistochemically in sera of NOD mice as autoimmune type 1 diabetic model and IRS2-deficient mice using pancreatic sections prepared from mice before (control mice) and after (diabetic mice) onset of FT1DM. Activities of HK and GK in glycolysis and MDH in the malate-aspartate shuttle in cytosolic fraction of liver in the diabetic mice were significantly lower than those of the control mice. Protein is commonly recommended as part of a bedtime snack to maintain normal blood sugar levels during the night, although studies are mixed over whether it adds any protective benefits against nighttime hypoglycemia. Activities of FBPase in gluconeogenesis and ME in fatty acid synthesis in liver of the diabetic mice were significantly higher than those of the controls. In the mitochondrial fraction of liver of the diabetic mice, activities of 3-HBD were significantly higher than the controls, whereas activities of AST and PC were significantly lower than those of the controls. In the liver of the diabetic mice, activities of cytosolic LDH, G6PD, AST and mitochondrial GLDH were lower than those of the control mice.
Evidence suggests that eating moderate amounts of fish (twice a week) may improve triglycerides and help lower the risks for death from heart disease, dangerous heart rhythms, blood pressure, a tendency for blood clots, and the risk for stroke.The most healthy fish are oily fish such as salmon, mackerel, or sardines, which are high in omega-3 fatty acids. The clinical symptoms of FT1DM observed in male IRS-2 deficient mice are significant increase in plasma glucose and cholesterol concentrations and a significant decrease in plasma insulin and C-peptide concentrations.
Three capsules of fish oil (preferably as supplements of DHA-EPA) are about equivalent to one serving of fish.Women who are pregnant (or planning on becoming pregnant) or nursing should avoid fish that contains high amount of mercury. All diabetic mice showed reduction of body weight, glycosuria and ketonuria and they were considered to fall into complete insulin deficiency. In the diabetic mice with insulin deficiency, their plasma TG and FFA concentrations were expected to increase generally, however those concentrations were not changed in IRS-2 deficient diabetic mice. In our previous report (Hashimoto et al., 2006), plasma TG and FFA concentrations decreased significantly notwithstanding plasma glucose and cholesterol concentrations increased significantly in the diabetic IRS-2 deficient mice at 14 weeks old. It is rich in both soluble and insoluble fiber, omega-3 fatty acids, and provides all essential proteins. Liver-specific insulin receptor knockout (LIR-KO) mice with remarkable insulin resistance showed a significant decrease in their plasma TG and FFA concentrations. As IRS-2 deficient mice seemed to have unique regulation mechanism of plasma TG and FFA concentrations, their characteristics in lipid metabolism should be further studied in more IRS-2 deficient mice.
They also contain polyunsaturated fats, which are better than the saturated fat found in meat. In livers of the diabetic IRS-2 deficient mice, activities of enzymes in glycolysis and the malate-aspartate shuttle were significantly decreased, whereas those in gluconeogenesis and ketone body synthesis were significantly elevated. Decreased activities of pyruvate carboxylase, supplying oxaloacetate to the TCA cycle, suggested depression of citrate synthesis, the rate limiting reaction of TCA cycle, and activation of ketone body synthesis. It contains only a trace amount of soy and is very high in sodium.For many years, soy was promoted as a food that could help lower cholesterol and improve heart disease risk factors.
Decrease in glycolysis or increase in gluconeogenesis and ketone body synthesis may be typical metabolic changes induced by complete insulin deficiency. Recent studies have found that soy protein and isoflavone supplement pills do not have major effects on cholesterol or heart disease prevention.
Decreased activities of LDH, MDH, AST and GLDH in the diabetic IRS-2 deficient mice reflected depression of liver function frequently observed in the diabetic animals. The American Heart Association still encourages patients to include soy foods as part of an overall heart healthy diet but does not recommend using isoflavone supplements.Meat and Poultry. Pathology and islet antibodies in IRS-2 deficient mice with FT1DMOn histopathological examination, the pancreatic islets of the diabetic mice were significantly decreased in size and number compared to those of the control mice.
In particular, size and number of insulin secreted ? cells in the diabetic mice decreased significantly compared to those in the controls, whereas number of glucagon secreted ? cells decreased a little.
Remarkable insulitis by autoimmunity was not observed in pancreatic sections in the diabetic mice (Figure 3). A high intake of dairy products may lower risk factors related to type 2 diabetes and heart disease (insulin resistance, high blood pressure, obesity, and unhealthy cholesterol).
In the sera of the diabetic NOD mice, the islet-related antibodies reacted with their own islets (Figure 4, B1) and IRS2-deficient mouse islets before (Figure 4, B2) and after (Figure 4, B3) onset of FT1DM.
Some researchers suggest the calcium in dairy products may be partially responsible for these benefits. In the serum of the control NOD mouse without glycosuria, the islet-related antibodies were not observed (Figure 4, A1-3).
Vitamin D contained in dairy may also play a role in improving insulin sensitivity, particularly for children and adolescents.
In sera of control and diabetic IRS2-deficient mice, the islet-related antibodies were not observed (Figure 4, C1-3 and D1-3). However, because many dairy products are high in saturated fats and calories, it’s best to choose low-fat and nonfat dairy items.Fats and OilsSome fat is essential for normal body function. The cause of this degeneration might be increased adiposity due to increased activities of lipogenic enzymes (such as ACL, FAS, and ME) before the change of glucose tolerance in IRS-2 deficient mice. The type of fat is more important than the total amount of fat when it comes to reducing heart disease. We consider that macrophages noted on histopathologic examination likely appeared to phagocytize the degraded collagen fibrinoid induced by fatty degeneration.In the diabetic IRS-2 deficient mice, hepatic steatosis is frequently observed.
Monounsaturated fatty acids (MUFA) and polyunsaturated fatty acids (PUFA) are “good” fats that help promote heart health, and should be the main type of fats consumed. The finding of severe, selective destruction of pancreatic ? cells was considered to be one of the characteristics in FT1DM in IRS-2 deficient mice. The diabetic IRS-2 deficient mice did not show the islet-related antibodies observed in the diabetic NOD mice as autoimmune T1DM model. The destruction mechanism of pancreatic islet cells in IRS-2 deficient mice may differ clearly from that in the diabetic NOD mice. In order to calculate daily fat intake, multiply the number of fat grams eaten by nine (1 fat gram provides 9 calories, whether it's oil or fat) and divide by the number of total daily calories desired. IRS-2 deficient mice develop diabetes because of insulin resistance in the liver and failure to undergo ? cells hyperplasia. Progress of changes in islet mass should be further studied to investigate pancreatic ? cells destruction. At the moment abrupt increase in plasma concentrations and appearance of ketonuria are available indicators to decide complete insulin deficiency caused by pancreatic ? cells destruction in diabetic mice.
The American Heart Association recommends that fats and oils have fewer than 2 grams of saturated fat per tablespoon.Try to replace saturated fats and trans fatty acids with unsaturated fats from plant and fish oils.
In IRS-2 deficient mice, the sterol regulatory element binding protein (SREBP)-1 downstream genes, such as ATP citrate lyase and fatty acid synthase genes, are significantly increased and an excess amount of lipid is accumulated in their tissues. Omega-3 fatty acids, which are found in fish and a few plant sources, are a good source of unsaturated fats. Accumulated lipid is also considered to be one of the causes of injury to their pancreatic islets.
Generally, two servings of fish per week provide a healthful amount of omega-3 fatty acids. Fish and fish oil supplements contain docosahexaenoic (DHA) and eicosapentaenoic (EPA) acids, which have significant benefits for the heart. Discuss with your doctor whether you should consider taking fish oil supplements.Low-Fat Diets. The American Diabetes Association states that low-fat diets can help reduce weight in the short term (up to 1 year). Low-fat diets that are high in fiber, whole grains, legumes, and fresh produce can offer health advantages for blood sugar and cholesterol control.Dietary CholesterolAnimal-based food products contain cholesterol. Because of the lack of scientific evidence for benefit, the American Diabetes Association does not recommend regular use of vitamin supplements, except for people who have vitamin deficiencies.Patients with type 2 diabetes who take metformin (Glucophage) should be aware that this drug can interfere with vitamin B12 absorption.
Calcium supplements may help counteract metformin-associated vitamin B12 deficiency.Sodium (Salt)It is important for everyone to restrict their sodium (salt) intake. Limiting or avoiding consumption of processed foods can go a long way to reducing salt intake.
Simply eliminating table and cooking salt is also beneficial.Salt substitutes, such as Nusalt and Mrs. Dash (which contain mixtures of potassium, sodium, and magnesium) are available, but they can be risky for people with kidney disease or those who take blood pressure medication that causes potassium retention.
Similarly, while eating more potassium-rich foods is helpful for achieving healthy blood pressure, patients with diabetes should check with their doctors before increasing the amount of potassium in their diets. Diabetic NOD (B1-3), control IRS-2 (C1-3) and diabetic IRS-2 (D1-3) mouse sera reacted with pancreatic sections, respectively.5.
Calcium supplements may be important in older patients with diabetes to help reduce the risk for osteoporosis, particularly if their diets are low in dairy products.Potassium and Phosphorus.
Potassium-rich foods, and potassium supplements, can help lower systolic and diastolic blood pressure. Current guidelines encourage enough dietary potassium to achieve 3,500 mg per day for people with normal or high blood pressure (except those who have risk factors for excess potassium levels, including kidney disease and the use of certain medications).
This goal is particularly important in people who have high sodium intake.The best source of potassium is from the fruits and vegetables that contain them.
Potassium-rich foods include bananas, oranges, pears, prunes, cantaloupes, tomatoes, dried peas and beans, nuts, potatoes, and avocados. Kidney problems can cause potassium overload, and medications commonly used in diabetes (such as ACE inhibitors or potassium-sparing diuretics) also limit the kidney's ability to excrete potassium. Patients with diabetic nephropathy (kidney disease) and kidney failure need to restrict dietary potassium, as well as phosphorus. Phosphorus-rich foods that should be avoided include meats, dairy products, beans, whole foods, and nuts. In addition, many processed and fast foods contain high amounts of phosphorus additives.Magnesium. Whole grain breads and cereals, nuts (such as almonds, cashews, and soybeans), and certain fruits and vegetables (such as spinach, avocados, and beans) are excellent dietary sources of magnesium. Persons who live in soft water areas, who use diuretics, or who have other risk factors for magnesium deficiency may require more dietary magnesium than others.Chromium.
Most studies have indicated that chromium supplements have little or no effect on glucose metabolism and may cause adverse side effects.Selenium. The American Diabetes Association recommends limiting alcoholic beverages to 1 drink per day for non-pregnant adult women and 2 drinks per day for adult men.Coffee. Many studies have noted an association between coffee consumption (both caffeinated and decaffeinated) and reduced risk for developing type 2 diabetes. Researchers are still not certain if coffee protects against diabetes.Herbal RemediesGenerally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful.
There have been a number of reported cases of serious and even lethal side effects from herbal products.
Patients should always check with their doctors before using any herbal remedies or dietary supplements.Traditional herbal remedies for diabetes include bitter melon, cinnamon, fenugreek, and Gymnema sylvestre.
Few well-designed studies have examined these herbs’ effects on blood sugar, and there is not enough evidence to recommend them for prevention or treatment of diabetes.Various fraudulent products are often sold on the Internet as “cures” or treatments for diabetes.
The FDA warns patients with diabetes not to be duped by bogus and unproven remedies.Weight Control for Type 2 DiabetesThe American Diabetes Association recommends that patients aim for a small but consistent weight loss of ? - 1 pound per week.
There are many approaches to dieting and many claims for great success with various fad diets. When overweight people achieve even modest weight loss they reduce risk factors in the heart. Ideally, overweight patients should strive for 7% weight loss or better, particularly people with type 2 diabetes.A regular exercise program is essential for maintaining weight loss.
For patients who cannot lose weight with diet alone, weight-loss medications such as orlistat (Alli, Xenical) may be considered.
Very-low calorie diets have also been associated with better success, but extreme diets can have some serious health consequences.To determine the daily calorie requirements for specific individuals, multiply the number of pounds of ideal weight by 12 - 15 calories. For instance a 50-year-old moderately active woman who wants to maintain a weight of 135 pounds and is mildly active might need only 12 calories per pound (1,620 calories a day).
A 25-year old female athlete who wants to maintain the same weight might need 25 calories per pound (2,025 calories a day).Fat intake should be no more than 30% of total calories. Avoid saturated fats (found in animal products).ExerciseAerobic exercise has significant and particular benefits for people with diabetes. Regular aerobic exercise, even of moderate intensity (such as brisk walking), improves insulin sensitivity.
People with diabetes are at particular risk for heart disease, so the heart-protective effects of aerobic exercise are especially important.Exercise Precautions for People with Diabetes. The following are precautions for all people with diabetes, both type 1 and type 2:Because people with diabetes are at higher than average risk for heart disease, they should always check with their doctors before undertaking vigorous exercise.
Moderate-to-high intensity (not high-impact) exercises are best for people who are cleared by their doctors.
For people who have been sedentary or have other medical problems, lower-intensity exercises are recommended.Strenuous strength training or high-impact exercise is not recommended for people with uncontrolled diabetes.
Patients who use blood pressure medication should consult their doctors on how to balance medications and exercise. Patients with high blood pressure should also aim to breathe as normally as possible during exercise. Diabetic Exchange ListsThe objective of using diabetic exchange lists is to maintain the proper balance of carbohydrates, proteins, and fats throughout the day. Patients should meet with a dietician or diabetes nutrition expert for help in learning this approach.In developing a menu, patients must first establish their individual dietary requirements, particularly the optimal number of daily calories and the proportion of carbohydrates, fats, and protein.



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