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Diabetes: Our Real Epidemic

No exaggeration. Diabetes has reached #epidemic proportions in both developed and developing countries, affecting more than 366 million people worldwide. It's anticipated that this number will continue to increase which comes as no surprise to myself, as our food industry is plagued with unhealthy and addictive food-like substances, our stress levels are off the chart yet completely tolerated, and our lifestyles are consumed by business that keep us immobile. No one sleeps effectively anymore and we can't even define pleasure or self-care.


As a practitioner, I can see diabetes coming years ahead of its ultimate diagnosis. Men who can't get erections are headed towards diabetes and heart disease within a few short years. Women whose arms are almost as large as their legs are diving straight into diabetes. Do you have a hump below your neck or a roll at the base of your skull - yep, you have diabetes on the horizon.


This doesn't just impact adults either; children are more frequently diagnosed with type two diabetes than ever before. While many clinicians ignore this fact, diabetes impacts virtually every organ in the body. The gastrointestinal tract is an area in particular that seems to go unrecognized, but when properly monitored can not only improve diabetes management but also quality of life.


Heartburn & Reflux


As many as 63% of diabetics suffer with esophageal dysmotility and this doesn't seem to differ with type one or type two diabetes or between genders. Interestingly, this was strongly associated with retinopathy, so if you have reflux and diabetes, be sure you are also seeing your optometrist. The esophagus has smooth muscle fibers which are innervated by myenteric plexus which are ultimately impacted by diabetic neuropathy, similar to those who lose sensation in their feet. This causes abnormal peristalsis, spontaneous contractions and reduced lower esophageal sphincter tone.


Reflux symptoms are reported in about 41% of diabetics and those with neuropathy were found to have higher rates of erosive esophagitis (66.7%) compared to (33.3%); also asymptomatic erosive esophagitis was more frequent. Gastroesophageal reflux disease was found to be inversely related to glycemic control, so if you have reflux or heartburn, your blood sugar is likely to be worse, and if you were to have better glycemic control, you would likely improve your esophageal dysmotility and reflux.


There are a number of new diagnostic methods. Management may include prokinetic drugs such as metoclopramide, but there are a number of herbal remedies which are quite effective as well. A two-week course of erythromycin has also been shown to reduce esophageal transit time and gastric emptying. When taking pills, it is important to drink a significant amount of water afterward to assure they have flushed through the esophagus and not be contributing to the problem.


Delayed Gastric Emptying


Another issue more common among diabetics, about 30% and higher in women. Obesity is a major player here, as well as neuropathy. The longer one has diabetes, the greater the incidence and severity which relates to more macro- and microvascular complications. Delayed gastric emptying contributes to poor glycemic control as well.


Endoscope findings are consistent with enteric neuropathy in these clients. A deficiency of apolipoprotein E may be a risk factor. These clients may suffer nausea, vomiting, early satiety, postprandial fullness, bloating and upper abdominal pain. When clients have unexplained alternating between hyperglycemia and hypoglycemia the clinician should evaluate for diabetic gastroparesis.


About 53% lose weight, but 18-24% may gain. More than half identify their symptoms as more acute, but certainly there are those which have a more insidious onset. One third have chronic symptoms with periodic exacerbations and one third have chronic worsening symptoms. Beyond the extensive health history and physical, an upper GI series with small bowel follow-through or small bowel MRI may be helpful. If significant pain is present, an ultrasound can help rule out bilary colic. The diagnosis of gastroparesis is made by gastric emptying scintigraphy using Tc sulphur colloid bound to solid food. This noninvasive, quantitative method is considered the gold standard test for diagnosing gastroparesis.


Diarrhea, Constipation, & Fecal Incontinence


Advanced cellular damage occurs with long term and unregulated diabetes which impacts the health of every organ, including the brush border of the gut and colon. A slower moving gut results in motility issues, leading to constipation. Small intestinal bacterial overgrowth (SIBO) can result in diarrhea and is often the consequence of intestinal stasis. The alternating presence of diarrhea and constipation is a common symptom of diabetic enteropathy.


Diarrhea may be painless and associated with fecal incontinence that occurs more during the day. More often this is the result of poorly controlled diabetes and ultimately suffer from peripheral and autonomic neuropathy. It may also be the result of pancreatic insufficiency, bile salt malabsorption, steatorrhea and drugs such as metformin. Endoscopic examination is helpful and ruling out SIBO.


NonAlcoholic Fatty Liver Disease


This diagnosis results from either imaging or histology and alcohol consumption, use of steatogenic medication and hereditary disorders have been ruled out. NAFLD is considered to be the hepatic manifestation of metabolic syndrome, which is hyperinsulinemia with insulin resistance, visceral obesity, dyslipidemia and hypertension. NAFLD is now the most common cause of chronic liver disease in North America, with 6.3 to 33% of the population affected. One study found that 69% of those with type two diabetes have NAFLD, while other studies have found as high as 87%.


The majority of these clients are asymptomatic, some may suffer malaise and right upper quadrant pain. One may have mildly elevated liver enzymes or even severe liver disease with fibrosis and nodular degeneration. Twenty percent of those with NASh will develop cirrhosis and about 40% of these cirrhotic patients will develop decompensated liver disease. Diabetes, obesity, cirrhosis-associated carcinogenic facts all play a role in morbidity for those with NAFLD. Several factors including tumor necrosis factor alpha, oxidative stress, adiponectin, leptin, apoptosis and genetic factors are believed to play a role in the pathogenesis of NAFLD and NASH. Lifestyle modifications is the cure here. Vitamin E supplementation is another potential treatment modality for those without diabetes.


If your doctor isn't talking to you about these issues, advocate for yourself. Optimal health is the goal. If you are willing to invest in yourself, functional medicine doctors are eager to support your effort. Call me!


Krishnan, B., Babu, S., Walker, J., Walker, A. B., & Pappachan, J. M. (2013). Gastrointestinal complications of diabetes mellitus. World J Diabetes, 4(3), 51-63.

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