This summary relies heavily on the podcast “The Drive with Peter Attia — Jake Kushner“. The show-notes of this excellent episode contain more relevant details, charts, book recommendations and resource links. Any mistakes in the summary below are mine.
Summary
- Introduction.
- Detailed Progression.
- Role of Pancreas.
- Diabetes Detection.
- Diabetes Test.
- Diabetes Treatment.
- Role of Insulin.
- Managing Insulin and Blood Sugar.
- Role of (Endurance) Exercise.
- Low Carb Solution.
- Protein, Glucose and Insulin.
Introduction.
- Type 1 diabetes = very little or no insulin.
- Insulin is produced by the pancreas.
- Low insulin results in high blood sugar levels in the body.
- Affects approximately one in 300 people.
- The cause of type 1 diabetes is unknown.
- Believed to involve a combination of genetic and environmental factors.
- Involves autoimmune destruction of beta cells.
- Beta cells in the pancreas produce insulin.
- Beta cells that are destroyed release their unique content.
- This triggers an autoimmune response.
- The autoimmune response includes certain unique antibodies.
- The appearance of unique autoantibodies is a signal.
- Indicates potential for type 1 diabetes:
- Islet cell autoantibodies, insulin autoantibodies, autoantibodies targeting the 65-kDa isoform of glutamic acid decarboxylase (GAD), autoantibodies targeting the phosphatase-related IA-2 molecule, and zinc transporter autoantibodies (ZnT8).
- Indicates potential for type 1 diabetes:
- Type 1 diabetes is different than type 2.
- Type 2 diabetes is characterized by insulin resistance.
- Type 1 diabetes is characterized by insulin deficiency, generally without insulin resistance.
- Test for type 1 by testing for the presence of autoantibodies.
Detailed Progression.
- Beta cells, which secrete insulin, dump off antigens.
- Antigens begin to provoke the immune system locally.
- Immune cells start to destroy beta cells, resulting in more antigens being dumped.
- End result is a progressive autoimmunity, where you lose beta cells over time.
- Adults have a greater reserve of beta cells so onset takes longer and is slowly progressing.
Role of Pancreas.
- 95% of the pancreas serves an exocrine function:
- Mostly there to help local digestion system.
- 5% of the pancreas acts as an endocrine organ:
- Secretes systemic hormones into the system (including insulin).
Diabetes Detection.
- When a person suffers a problem that may be caused by diabetes:
- Such as a heart attack, stroke, neuropathy, poor wound healing or a foot ulcer.
- General symptoms include:
- Frequent urination.
- Increased thirst.
- Increased hunger.
- Weight loss.
- Or: blurry vision, feeling tired, and poor wound healing.
- Symptoms typically develop over a short period of time.
Diabetes Test.
- Diagnosed by testing:
- The level of sugar or glycated hemoglobin (HbA1C) in the blood.
- Oral Glucose Tolerance Test.
- Varying indications of risk levels.
Diabetes Treatment.
- Treatment with insulin is required for survival.
- Insulin therapy is usually given by injection but can also be delivered by an insulin pump.
- Diet and exercise are important parts of disease management.
- Target range of blood glucose differs, but about 80-140 mg/dl.
Role of Insulin.
- Insulin is a key factor in regulating virtually every cell in the body.
- It’s about recognizing whether a cell is in a state of feast or famine.
- If in feast: it takes the nutrients and parks them in the cell.
- In a famine: it will mobilize some nutrients and make them available to keep the organism alive.
- Insulin is a master regulator of your state of metabolism.
- In a muscle cell:
- In a fed state:
- Promotes glucose uptake into skeletal muscle.
- Insulin signal tells the glucose transporter to move to the cell wall.
- GLUT4, a glucose transporter, translocates from the cytosol to the cell wall, which makes the muscle cell permeable for glucose to be shuttled in.
- In a state of starvation:
- At a cellular level, people with T1D are starving.
- Muscle is broken down and used for gluconeogenesis.
- It creates a profound negative nitrogen balance.
- In a fed state:
- In a muscle cell:
- Insulin influences many of the major steps of protein metabolism .
- In the presence of insulin, you’re putting more glycogen into skeletal muscle, or in the absence you’re going to break them down.
- And IGF-1:
- If insulin goes up, IGF-1 goes up. (see SHBG write-up)
Managing Insulin and Blood Sugar.
- The challenge of controlling blood sugar in T1D due to variance of reaction to food:
- Too much insulin may cause hypoglycemia, dangerously low levels of blood glucose.
- Difficult to predict the impact of carbs.
- Stress, sleep quality, exercise all have an impact.
- Other things in food, like fat and protein, also alter gastric emptying and glucose conversion.
- Potential for weight gain:
- Hiking up insulin and overshooting blood glucose (too low):
- Need to eat carbs to compensate.
- End up “chasing carbs”.
- Weight gain.
- Hiking up insulin and overshooting blood glucose (too low):
- Blood glucose goals:
- Target absolute levels as well as variance (standard deviation).
- Possible future “cures”:
- Stem cells
- Auto-loop pancreas that would measure your glucose and administer insulin.
- Beta cell regenerative therapy
- Something that just shuts down the autoimmune system??
Role of (Endurance) Exercise.
- People can use exercise can help people control their diabetes
- Part of the mechanism is via the insulin-independent glucose uptake into skeletal muscle via AMP kinase
- An enzyme that is sensing the energy status of the cell
- If you alter the energy status of the cell through a tremendous amount of work (exercise), it signals the GLUT4 to translocate to the membrane of the skeletal muscle
- So now you get insulin-independent glucose uptake into skeletal muscle
- More likely to happen in endurance than strength exercise.
Low Carb Solution.
- The Law of Small Numbers.
- If you consume more carbs, you need more insulin and therefore there’s a greater opportunity to make a mistake.
- If you consume fewer carbs, you will consume less insulin and you’ll have fewer mistakes
- Avoid carbohydrates and apply medium and long acting insulin to cover protein and fat and basal metabolic requirements.
- Low carb, high protein diet.
- Use regular insulin (i.e. human insulin), not fast-acting insulin (i.e. Novolog).
Protein, Glucose and Insulin.
- 10 grams of protein ends up being about 6 grams of carbohydrate.
- Kinetics are not immediate.
- You don’t get gluconeogenesis in a matter of seconds, it’s delayed over hours.