diabetes management lecture 3

Introduction to Human Physiology (Know how your body works so you can treat your

diabetes effectively)

Lecture 3

by Eric Holzman

A Diabetic’s Guide to Managing Diabetes

by Eric Holzman9-18-07 2

Knowledge of human physiology is important in the management of diabetes

• Learning to control your blood glucose level is like learning to maintain your own car.

– Auto-mechanics understand how cars work.

• Doctors are human body “mechanics”.

– A doctor understands how the human body works.

– A doctor uses his knowledge and experience to diagnose and treat medical problems.

• We need to understand how the body regulates its blood glucose level.

• Your blood glucose level is affected by the activity of a number of organs and glands.

– pancreas and adrenal glands

– Stomach and intestines

– Liver



Diabetes prevents our body from producing the energy we need to live

• The human body is an engine that “burns” fuel to make energy.

• Our fuel comes from the food we eat and the air we breath.

• We need energy to live.

– Muscle action: digestion, blood circulation, breathing,…

• Cells are the body’s energy producers.

– Cells extract energy from foods that react with the oxygen we breathe.

• Metabolism: the energy-producing chemical reactions in the body’s cells.

• Diabetes inhibits the body’s metabolic processes.

– It prevents glucose from crossing the cellular barrier.

– No glucose in cells means no energy for the body.

diabetesglucose

energycell

blood



The main purpose of the food we eat is to provide the energy we need to live

• The food we eat can be divided into macronutrients and micronutrients.

• Macronutrients, carbohydrates, protein, and fat, are consumed in large quantities to provide energy.

• Energy in – Energy expended = weight change

intoxication7.07.0Alcohol (ethanol)

5.5

9.4

4.2

Total

Energy content (Kcal/gram)

4.1

9.1

4.1

Usable

Protein

Fat (lipid)

Carbohydrate

Macronutrient

Builds body tissue

Builds cell membranes, hormone release

Fiber for digestion

Other Purpose Source, Smil, pp. 93-94.

• On most nutrition labels, the word “calorie” is used in place of “kilocalorie”.• 28 grams = 1 ounce



Micronutrients--essential for normal body metabolism

• Micronutrients, vitamins and minerals, are needed in small quantities to sustain the body’s metabolic reactions.

• Vitamins are organic compounds.

• Minerals are basic atomic elements.

carbohydrate, fat metabolismPantothenic acidprotein metabolismB6 (Pyridoxine)growth, blood cell formationB12normal growthFolic acidblood clottingKnormal growthECalcium absorptionD

growth of tissue, cartilage, bone and teeth

C (Ascorbic acid)cell energy productionNiacincell energy productionB2 (Riboflavin)nervous system metabolismB1 (Thiamine)

cell growth, prevent “night blindness”

ANeeded forVitamin

Source, Guyton and Hall, p. 809-813. Metabolism, protein digestion

Zinc (Zn)

Bone formation, carbohydrate metabolism

Manganese (Mn)

Copper (Cu)Cobalt (Co)

Carbohydrate metabolismMagnesium (Mg)Cellular metabolismIodine (I)

Oxygen transport, cellular oxidation

Iron (Fe)Metabolism, bonesPhosphorus (P)BonesCalcium (Ca)

Chlorine (Cl)Potassium (K)

Transport across cellular membrane

Sodium (Na)Needed forMineral



Carbohydrate--our body’s preferred source of energy

• Carbohydrate (CHO): chain of sugars, carbon-hydrogen-oxygen

• Sources: plants, particularly grains (wheat, barely,…), rice, potatoes

– Animal meat contains very little or no carbohydrate.

• Carbohydrate is preferred over fat and protein as an energy source.

– The body will use carbohydrates first, then switch to fat and lastly, protein.

• Excess carbohydrate is stored in fat and liver cells with aid of insulin.

• Glucose: a sugar that is the building block of most carbohydrates.

• Carbohydrate is converted to glucose by the digestive track and liver before reaching our cells.

• Decrease in blood glucose causes feeling of hunger.

Bernstein, pp. 365, 366, 368.Guyton & Hall, pp. 19, 786, 806.



Fat--Not All Bad

• Lipids or Fat: Used for energy, muscle activity, hormone release, formation of cell membranes.

• Sources are both animal and plant—CHO is also converted to and stored as fat (triglycerides) by the liver.

• Major source of energy after CHO.

– 9 cal/gram—provides as much energy as CHO.

• Energy storage: fat stored in the liver and in fat cells (adipose tissue).

• Cholesterol—promotes digestion of fats, forms cell membranes, skin

– LDL (low density lipoprotein) is bad: causes Atherosclerosis (clogged arteries).

– HDL (high density lipoprotein) is good: reduces risk of Atherosclerosis.

• Dietary fat—good or bad?

– Saturated fat raises cholesterol level in blood

– Unsaturated fat decreases cholesterol level

– Too much fat may lead to weight gain Guyton & Hall, pp. 19, 781-789.Bernstein, pp. 112-116Smil, p.94



Protein

• Protein: essential for normal human growth and formation of most body tissue, immunity (globulin), blood clotting (fibrinogen)

• ¾ of body solids are proteins: primary constituents are 20 amino acids

– 10 amino acids synthesized in human body

– 10 essential amino acids most come from our diet

• Sources are animal and plant (beans, cereals and nuts) foods

– Complete protein, has all essential amino acids, in animal foods & mushrooms.

– Minimum of 20-30 grams required per day—60-75 grams recommended.

• Used by body only after CHO & fat sources are emptied—4 cal/gram

– Starvation

– Untreated type 1 diabetes

• Liver can convert protein to energy, store as fat or glycogen (glucose).

Guyton & Hall, pp. 791-796.Source, Smil, p. 94.



The Human Body Continually Switches from Carbohydrate to Fat for Energy

• We switch between metabolizing carbohydrate and fat for energy.

• Shortly after we eat most food that is metabolized is carbohydrate.

• Fasting: 8-10 hours after a meal, readily available carbohydrate stores are empty, and nearly all energy is derived from fat.

• Exercise burns carbohydrate or fat depending on its timing.

– before eating, fat is metabolized

– shortly after eating, carbohydrate is metabolized

• Between meal snacking on carb-dense foods suppresses fat metabolism.

• Untreated diabetes: without insulin, carbohydrate cannot be metabolized no matter how much food is consumed.

Guyton & Hall, pp. 804.

Breakfast Lunch Dinner Breakfastfat CHO fat CHO fat CHO fat



Gastrointestinal Fundamentals—What Happens to the Food We Eat?

• The digestive system, or alimentary tract, provides the body with important products:

– Water

– Electrolytes: sodium, potassium, chloride

– Nutrients (CHO, Protein, Fat, Vitamins & Minerals)

• The body processes the food we eat by:

– moving the food through the tract

– Secreting digestive juices and digesting the food

– Absorbing digestive products

– Circulating blood through the tract to carry away the absorbed substances

– Controlling all these functions with the nervous and hormonal systems

Guyton & Hall, p. 718.



Gastrointestinal Fundamentals—How Food is Processed by Your Body

• Chewing—aids in digestion of food, particularly raw fruits and vegetables.

• Swallowing—movement of food from mouth to the stomach via the esophagus.

• The stomach has several functions– stores food before intestinal digestion.

– Mixes food with digestive juices to make chyme.

– Empties chyme into small intestine at a rate controlled by small intestine.

• Small intestine mixes & conveys chyme for several hours.

• Colon absorbs water & electrolytes; forms, stores & expels feces.

• The more one eats at a meal, the longer the digestive process will last.

• Fats and proteins take the longest to digest.

Guyton & Hall, pp. 728, 730-733.



Gastrointestinal Fundamentals—The Role of Glands

• Throughout the alimentary tract, a variety of glands aid in digestion by secreting hormones, enzymes and mucus.

• Pancreas secretes digestive juices through a duct into intestine when chyme is present.

– Enzymes for digesting all three macronutrients.

– Sodium bicarbonate for neutralizing the acidic chyme.

• Liver aids in fat digestion by secreting bile (primarily water & cholesterol-based salts).

Guyton & Hall, pp. 738, 746-751.



Digestion--the break down of macronutrients into molecules that can be absorbed

• The macronutrients we eat cannot be absorbed by the body without digestion.

• Hydrolysis is the basic digestive process: water plus enzymes break down the macronutrient molecules into smaller molecules.

• The small intestine absorbs nearly all the body’s nutrients.

– CHO (100s of grams), fat (100+ grams), protein (50-100 grams), water (7-8 liters).

• Most dietary carbohydrate comes from one of three major sources.

– Sucrose (cane sugar), Lactose (from milk), Starches (from plant-based food)

– Cellulose (fiber) cannot be hydrolyzed by humans.

• 80% of digestible carbohydrate is converted to glucose.– Sucrose fructose; lactose galactose are then converted to glucose by the liver.

– Glycemic index: measure of how fast CHO are digested & absorbed.

• More than 99% of ingested protein is broken down into individual amino acids.

• Animal fats are primarily in the form of triglycerides.

Guyton & Hall, pp. 754-756.



Metabolism of Carbohydrates


A fire oxidizes fuel to make heat• Cells oxidize macronutrients and produce large amounts of energy.

– For mechanical motion by muscles, glandular secretion,…

– Calories are units of energy liberated from a substance.

• Circulating blood carries CHO as glucose to tissue cells.

• A glucose molecule cannot be used by a tissue cell until it crosses the cell membrane. It is too large to do this on its own.

• Without insulin, the amount of glucose that passes across most cell membranes is far too little for normal metabolism.

– Exceptions are brain & liver cells

Your body oxidizes nutrients to make energy



• Glucose can be used by cells for energy immediately or stored as glycogen.

– Initiated by insulin, the “fat storing” hormone.

• All cells can store glycogen, but liver and muscle cells can store the most.

• Glycogenesis—storage of glucose as glycogen

• Glycogenolysis—breakdown of glycogen into glucose for energy.

– Initiated by hormones epinephrine (adrenal gland) & glucagon (pancreas α cells).

• In stressful situations, epinephrine release stimulates the release of stored glucose to muscles for action (“fight or flight”).

– In diabetics, this glucose release can lead to an unexpected rise in blood glucose. Viewing a scary or suspenseful movie can cause a release of epinephrine.

• Gluconeogenesis: formation of glucose from fat & protein; occurs when cellular glucose and blood glucose are low.

Cells store glucose in the form of glycogen


glucose glycogen glucose

glycogenesis glycogenolysis



Fat (Lipid) Metabolism

• Dietary fat (triglycerides) is absorbed from the intestines.

• Triglycerides are used mainly to provide energy.– Cholesterol is used to form cell membranes.

• Most fat is removed from the blood and stored as it passes through the fat tissue and/or liver.

– Liver can synthesize triglycerides from excess carbohydrate and protein.

– 150 times as much energy is stored in fat as carbohydrate.

• Fat is transported by the blood to other tissues for metabolism.

• Almost all the normal energy requirements of the body can be provided by fat without using any carbohydrate or protein.

– Almost all cells can use fat interchangeably with glucose for energy.

– Occurs during starvation and in un-treated type 1 diabetics.

Guyton & Hall, pp. 781-783, 785.



High-Fat Diets and Ketosis

• A bi-product of normal liver breakdown of fat is a minute amount of acetone.

• Ketosis: condition of high concentration of acetone (a ketone body) in the blood.

– occurs in starvation, un-treated type 1 diabetes & sometimes in high-fat diets

• Lack of available CHO causes body to use stored fat.

– Used by tissues cells for energy

– Converted to ketone bodies by liver

– Some acetone is exhaled—acetone breath is an indicator of ketosis.

• One can slowly convert from CHO to a fat diet without ketosis occurring.

– Traditional Inuit (Eskimos) diet almost entirely of fat.




The Facts About Cholesterol

• Cholesterol is a dietary fat, but most is formed in the body.

• Cholesterol makes the skin highly impenetrable to a variety of substances and resistant to water evaporation.

• LDL (low density lipoprotein) cholesterol increases risk of atherosclerosis (clogged arteries).

• HDL (high density lipoprotein) cholesterol reduces risk.


• Ingesting more cholesterol increases the blood concentration (up to 15%), but inhibits body’s production of cholesterol.

• A highly saturated (animal) fat diet increases blood cholesterol more (15% to 25%).

• Ingesting unsaturated fat (olive, nuts, avocado,…) decreases blood cholesterol up to a moderate amount.



Protein Metabolism

• The body needs 20-30 grams of protein per day.

• The molecules of all amino acids (proteins) are too large to pass through cell membranes unaided.

– Exact transport mechanisms are not well understood.

– Cells combine amino acids and store them as larger protein molecules.

• Insulin accelerates transport of some amino acids into cells.

– Total lack of insulin suppresses cellular protein storage.

• Once cell storage of protein reaches its limit, added protein is stored as fat or used as energy.

– Carbohydrate and fat normally are used before protein.


www.happycow.net/humor_images



Endocrinology–coordination of body functions by chemical messengers

Guyton & Hall, pp. 703-704, 836-838, 875, 876.

• Endocrine system involves glands or specialized cells that release chemicals (hormones) into the blood to influence function of cells at another location.

• Pancreas hormones

– insulin (β cells): promotes glucose entry in many cells, controls glucose metabolism

– glucagon (α cells): increases synthesis and release of glucose from liver into the body fluids

• Adrenal gland: helps body cope with stress

– cortisol: influences metabolism of macronutrients, increases rate of liver formation of glucose by 6-10 times.

– Epinephrine: “fight or flight” hormone

• Increases activity of the heart, can increase the metabolic rate of the entire body up to 100% above normal.

• Increases glycogenolysis in liver, glucose release into blood.

Stresses• Trauma• Infection• Intense heat or cold• Surgery• Debilitating disease



The Pancreas, Insulin and Glucagon

• The islets of Langerhans secrete insulin & glucagon directly into the blood.

– 1-2 million islets, about 0.3 mm in diameter

– Organized around small blood vessels (capillaries)

– Beta cells: secrete insulin, 60% of all cells

– Alpha cells: secrete glucagon, 25% of all cells


• Insulin secretion – increases in presence of energy-giving foods in the diet.

– inhibits glucagon secretion

– causes excess carbohydrate storage as glycogen in liver and muscles.

– causes fat storage in fat tissue, conversion of excess carbohydrates to fat.

– promotes protein uptake by cells and inhibits breakdown of proteins.



Insulin’s Affect on Carbohydrate Metabolism

• For much of the day, muscle tissue uses fat not glucose for energy.

– Resting muscle cell membranes are only slightly permeable to glucose.

– Between meals, insulin is secreted at a low level.

• Muscles use large amounts of glucose under two conditions:

– During moderate or heavy exercise, contracting muscles use glucose without extra insulin secretion.

– For a few hours after eating, insulin secretion is high, and muscles use glucose.

• Glucose is stored in muscles or used depending on activity level.

• Within seconds after insulin binds with the receptors on a cell, the transport of glucose into the cell increases greatly.

– Especially true for muscle and fat cells.

– Cells also become more permeable to amino acids, potassium, phosphate.




The liver keeps the body supplied with glucose during fasting periods

• At meal time, the pancreas secretes insulin in large quantities.– Up to about 100 grams (4 ounces) of the glucose absorbed after eating is

stored in the liver as glycogen.

– Bolus insulin secretion is the large amount of insulin that must be secreted at meal time to maintain a normal blood glucose concentration.

• Fasting: after digestion of the last meal is complete – the blood glucose concentration falls,

– causes the pancreas to decrease insulin secretion.

• Lack of insulin in the blood during fasting or diabetes causes– liver storage of glucose to cease

– liver glycogen to be converted back to glucose and released into blood to maintain body metabolic processes.

– A basal level of insulin must be secreted for uptake of the glucose.

– A poorly treated diabetic produces too little insulin to keep his liver from causing a steady rise in blood glucose level during fasting periods.




The brain needs glucose, but it does not need insulin

• Brain cells can use glucose without the assistance of insulin.

• Brain cells normally use only glucose for energy.

– They can use fat only with difficulty

• Hypoglycemic (low blood glucose) symptoms arise when the blood glucose level is too low.

– 20 to 50 mg/dL

– Light headedness, irritability fainting seizures coma.


• Many of the symptoms of low blood glucose affect our mental state.

• Diabetics need to learn to recognize them.



Insulin also affects fat and protein metabolism

• Insulin promotes synthesis and storage of fat.

• When insulin is not available, storage of large amounts of fat (weight gain) is not possible.

– Lowering carbohydrate intake will lower insulin secretion and fat storage.

• In untreated type 1 diabetics, a symptom of lack of insulin is weight loss.

• Insulin is required for protein synthesis and storage also.

– Both insulin and growth hormone are essential for growth.

– Lack of insulin eventually causes the body’s protein to be consumed.

• When I was diagnosed with type 1 diabetes, my insulin production was so low that I had lost 10% of my body weight.




Glucagon increases the blood glucose concentration

• Glucagon is a hormone secreted by the Pancreas alpha cells.

• Affects glucose metabolism by causing

– glycogenolysis: breakdown of liver glycogen into glucose

– gluconeogenesis: formation in liver of glucose from fat & protein

• Injection of a fraction of a gram can easily double blood glucose concentration within minutes.

• As blood glucose concentration increases,

– glucagon secretion decreases, and

– insulin secretion increases.

Guyton & Hall, p. 891-892.

I keep a glucagon syringe for low blood glucose emergencies. Injection of its contents into my body will release all my liver’s stored glucose.



Your blood glucose concentration is continuously varying

• The healthy human circulatory system contains about 1 teaspoon of glucose at all times.

• In a normal person, blood glucose is tightly controlled, usually 80-90 mg/dL of blood during fasting periods, and rarely much higher after eating.

Eating

Blood Glucose Concentration

gluc

agon

Exercise

HypoglycemiaStress

Insulin

pancreas

adre

nal

Fasting

dige

stio

n

liver

muscles

Insulin

injected

Bernstein, pp. 41-43Guyton & Hall, p. 893.



What is a Normal Blood Glucose Level?

• To care for ourselves, we diabetics need to know what is normal.

• The body is in a state of fasting when all food has been absorbed.

– The size of your last meal determines when fasting starts

– Typically, it is 3-4 hours

• A normal person has a fasting blood glucose level of 90 mg/dL.

• A normal person will rarely have a blood glucose level outside the range 80 to 100 mg/dL.

• Some literature defines “normal” to be a wider range, up to 140 mg/dL within an hour after a meal. Don’t be deceived! That’s rarely normal.

– Dr. Bernstein has “seen ‘nondiabetics’ with sustained blood sugars averaging 120 mg/dL develop diabetic complications.”

• Hypoglycemia: below normal blood glucose

• Hyperglycemia: above normal blood glucose

Bernstein, pp. 41-43Guyton & Hall, pp. 780.



Type 1 diabetes has nothing to do with obesity

– Symptoms: increased blood glucose, thirst, loss of weight (fat and protein)

– Body mass is low to normal.

– Insulin sensitivity can be normal.

– In teenage juveniles, onset can be abrupt (days or weeks).

– In adults, it can take years for symptoms to become apparent (“honeymoon” period).

– Confirmed by a “positive” blood test for anti GAD antibodies.

• Type 1 diabetics don’t produce insulin, so the proper treatment is externally administered (exogenous) insulin.

Bernstein, pp. 34-41.Guyton & Hall, pp. 894.

• Lack of insulin causes impaired carbohydrate, fat & protein metabolism.

• Type 1 is an autoimmune disease: the immune system destroys the beta cells of the pancreas.



Type 2 diabetes and obesity are closely linked

• Type 2 diabetes is caused by insulin resistance, the degraded sensitivity of body tissues to the effects of insulin.

• Insulin resistance can force the pancreas to produce more than the normal amount of insulin—pancreas burnout may eventually result.

• Even a normal person experiences variation in resistance to insulin throughout the day.

• 80% of Type 2 diabetics are obese.

• Insulin resistance increases with age.

• Treatment involves

– weight loss normal insulin sensitivity

– exercise to reduce insulin resistance,

– medication to counter insulin resistance,

– exogenous insulin to assist pancreas.

Bernstein, pp. 43-45.Guyton & Hall, pp. 895.



Alcoholic beverages do not raise blood glucose, but…

• Unsweetened alcoholic drinks such as beer, wine and hard liquor do not raise your blood glucose level.

• The liver metabolizes alcohol.

• Alcohol (ethanol) can indirectly lower the blood sugar of Type 1diabetics if consumed at meal-time.

– Can prevent liver from converting the protein in a meal into glucose.

– Most likely to occur for people on low carb diets.

• Symptoms of hypoglycemia are similar to alcohol intoxication.

• Too much alcohol consumption is not good--a healthy liver is essential for tight blood glucose control, whether you are diabetic or not.

Bernstein, pp. 118-120.



The female menstrual cycle complicates blood glucose control

• The hormones estrogen and progesterone are secreted at varying rates during the course of the female menstrual cycle.

– Increased levels of progesterone may cause increased insulin resistance hyperglycemia (high blood glucose).

– Increased levels of estrogen may cause increased insulin sensitivity hypoglycemia (low blood glucose).

• In one study, 2/3 of diabetic women reported elevated blood glucose levels during the week prior to the beginning of their menstrual period.

– More prevalent among women with premenstrual symptoms.

• Women with diabetes are more likely to experience irregular menstrual cycles than non-diabetics.

• During menopause, decreasing production of hormones can cause changes in insulin sensitivity.

Guyton & Hall, pp. 929-936. www.insulin-pumpers.org/howto/menses3-1.html

+



How do you know if you have diabetes?

• Diabetes: fasting blood glucose level tests above 126 mg/dL on two occasions.

• Pre-diabetes—fasting blood glucose level between 100 and 126 mg/dl. – You have type 1, and the autoimmune attack on your beta cells is underway

– You are at risk for type 2

• A random, non-fasting blood test above 200 mg/dL indicates you may be diabetic.– accompanied by the classic symptoms: increased thirst, urination, and fatigue.

– This test must be confirmed with a fasting blood glucose test.

• Oral glucose tolerance test: diabetes is diagnosed if glucose level is higher than 200 mg/dL after 2 hours

– This test is used mostly for type 2 diabetes.

• For pre-diabetes, it is still important that blood glucose control be near normal.– Your doctor may tell you are ok. You need to decide for yourself.

– Your impairment could develop into diabetes.

– Consistent post-prandial (after eating) readings of greater than 120 mg/dL are cause for concern.

– Take an HbA1c test every 6 months to monitor your condition.



Why is there a Type 2 diabetes epidemic among the world’s well-off?

• The wealthier people of the world exercise less and eat more.

– Drive cars instead of walk.

– Buy food from a market rather than grow it themselves.

– Hold sedentary rather than physically intensive jobs.

• They tend to be overweight.

– About 2/3 of US adults are overweight—1/3 are obese.

• The obese tend to be insulin-resistant

– An obese person produces two to three times more insulin then a slender non-diabetic.

• Because a type 2 diabetic produces insulin, complications may arise gradually without his/her knowledge.

• There is no easy solution to losing weight.

– People are addicted to food--life-time dieting requires will-power

– Daily exercise

http://www.obesityfocused.com/index.phpBernstein, pp. 45-47.



What should you know about Physiology to manage your diabetes?

• Macronutrients, carbohydrates, protein, and fat, provide energy.

• Immediately after we eat, nearly all the food that we metabolize is carbohydrate.

• The more one eats at a meal, the longer the digestive process will last.

• insulin: promotes glucose entry in many cells, controls glucose metabolism.

• Without insulin, the amount of glucose that passes across most cell membranes is far too little for normal metabolism.

• During exercise, contracting muscles use glucose without extra insulin secretion.

• In stressful situations, epinephrine release stimulates the release of stored glucose to muscles for action (“fight or flight”).

• A normal person will have a blood glucose level in the range 80 to 100 mg/dL.

• Type 1 diabetics don’t produce insulin, so the proper treatment is externally administered (exogenous) insulin.

• Type 2 diabetes is caused by insulin resistance, the degraded sensitivity of body tissues to the effects of insulin.

• A poorly treated diabetic produces too little insulin to keep his liver from causing a steady rise in blood glucose level during fasting periods.

• Unsweetened alcoholic drinks do not raise your blood glucose level.



Metric Units

• 28 grams (g) = 1 ounce

• 454 grams (g) = 1 pound

• 1 gram (g) = 1000 milligrams (mg)

• 1 liter (L) = 34 ounces

• 1 liter (L) = 10 deciliters (dL)

• Normal blood glucose level: 90 mg/dL



References

1. V. Smil, Energies: An Illustrated Guide to the Biosphere and Civilization, MIT Press, 1999.

2. R. Bernstein, Dr. Bernstein’s Diabetes Solution, Little, Brown and Company, 1997.

3. A. C. Guyton and J. E. Hall, Textbook of Medical Physiology, 10th edition, W. B. Saunders Company, 2000, Chapters 62-71, 74, 77, 78.

4. Cawood, Bancroft and Steel, “Perimenstral symptoms in women with diabetes mellitus and the relationship to diabetic control,” Diabet. Med, vol. 10, June 1993, pp. 444-448.

5. Kjaer, Hagen, Sand and Eshj, “Epidemiology of menarche and menstrual disturbances in an unselected group of women with insulin-dependent diabetes mellitus compared to controls,” J. Clin. Endorinol. Metab., vol. 75, Aug 1992, pp. 524-529.

6. Brown, Derby and Ng, “Cylcical disturbance of diabetic control in girls before the menarche,” Arch. Dis. Child, vol. 66, Nov 1991, pp. 1279-1281.

7. M. J. Franz, “Protein: New Research/New Recommendations,” Diabetes Self-Management, November/December 2001, pp. 85-87.

8. Images from Google™ Image Search at http://images.google.com

diabetes management lecture 3

Health & Medicine

energy source

diabetes fat

energy expended

energy storage

diabetes carbohydrate

diabetes diabetes

bodys energy producers

major source of energy