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  1. 1. HCV & Type 2 Diabetes: An Introduction By Liz Highleyman nile diabetes (because it usually devel- ops in children) or insulin-dependent Diabetes is a condition in which blood diabetes mellitus. In people with Type sugar levels are too high. This can occur 1 diabetes, the pancreas produces little when the body does not produce enough or no insulin (often because beta cells insulin or when cells do not use insulin have been destroyed by the body’s im- properly. Over time, high blood sugar lev- mune system). Symptoms typically de- els can lead to many complications, in- velop rapidly, and may include in- cluding nerve damage and loss of vision. creased thirst and appetite, frequent urination, and rapid weight loss. Peo- Sugar and Insulin ple with Type 1 diabetes must inject insulin. Your body needs a type of sugar called glucose as a fuel to provide energy. When • Type 2 diabetes is also known as the foods you eat are digested and broken adult-onset diabetes or non-insulin- down, glucose is released into the blood- dependent diabetes mellitus. It usually stream. In order for your cells to use this develops in older, overweight people. sugar, they require a hormone called insu- In people with Type 2 diabetes, either lin. Insulin acts as a “key” that allows glu- the pancreas does not produce enough cose to enter cells. Insulin is produced by insulin, the body cannot properly use beta cells located in the Islets of Langer- the insulin that is produced (insulin hans of the pancreas. resistance), or both. Some people with Blood glucose levels fluctuate over the this type of diabetes can control their course of the day. In most people, blood condition with diet and exercise modi- sugar rises after eating, but soon returns to fication, but others must take oral normal levels. But if there is not enough medications or insulin. insulin -- or if the body cannot properly use insulin -- glucose cannot enter the In addition, women may develop a condi- cells and builds up to high levels in the tion called gestational diabetes during blood (a condition known as hyperglyce- pregnancy. Blood sugar levels usually re- mia). When this happens, body and brain turn to normal once the baby is born. cells are starved for energy, and prolonged However, women who develop gestational high blood sugar can lead to a variety of diabetes while pregnant are at higher risk health problems. of later developing Type 2 diabetes. Types of Diabetes Type 2 Diabetes: the Basics There are two major types of diabetes: An estimated 16 million people in the U.S. (about 6% of the population) have Type 2 • Type 1 diabetes is also known as juve- diabetes; many of these people are un- Hepatitis C Support Project 1 HCV Advocate
  2. 2. (Continued from page 1) ple, in the September 1996 issue of Diabe- aware that they have the condition. Type 2 tes Care, Rafael Simo and colleagues re- diabetes is much more common than type 1, ported that study participants with diabetes accounting for over 90% of diabetes cases. had a 11.5% rate of HCV infection, com- Type 2 diabetes is more common among pared to a HCV rate of 2.5% in a matched Latino/Hispanic-Americans, African- population of non-diabetic blood donors. Americans, Asian/Pacific Islander- More recently, Nizar Zein and col- American, and Native Americans. Accord- leagues from the Mayo Clinic examined the ing to the National Institute of diabetes and prevalence of Type 2 diabetes in people un- Digestive and Kidney Diseases (NIDDK), dergoing liver transplants. They reported in Type 2 diabetes rates for Latinos and Afri- the February 2000 issue of the Journal of can-Americans are about twice the rate for Hepatology that the rate of diabetes was non-Hispanic whites; rates among certain higher in people who had end-stage cirrho- Native American tribes and Pacific Islander sis (liver scarring) related to HCV (25%) or groups are even higher. Some studies sug- alcoholism (19%) than in those with liver gest that certain racial and ethnic groups failure due to cholestatic (bile duct block- suffer higher rates of various long-term con- age) liver disease (1.3%). Interestingly, the ditions related to diabetes. For example, success rate for liver transplants was not ad- Mexican-Americans appear to have higher versely affected by diabetes. rates of retinopathy (eye disease) and kid- At the 10th International Symposium on ney disease than other people with diabetes. Viral Hepatitis and Liver Disease held in April 2000, Shruti Mehta and colleagues Risk Factors for Type 2 Diabetes from Johns Hopkins University examined Type 2 diabetes most often develops in the medical records of nearly 10,000 person adults over 40 years of age, but it may also taking part in the National Health and Nutri- occur in children and younger adults. Some tion Examination Survey. All were assessed experts now recommend that all people age for diabetes and hepatitis C; 1,242 (8.4%) 40 and older should be screened for diabe- had diabetes (type 1 or type 2) and 230 tes. People who are overweight and have a (2.1%) had HCV. After controlling for race, sedentary lifestyle (that is, they get little ex- injection drug use, and other factors, the re- ercise) are at greatest risk of developing the searchers found that in people age 40 and condition; in fact, about 80% of people with older, those with HCV were nearly four Type 2 diabetes are overweight. High blood times more likely to have Type 2 diabetes pressure and high levels of blood lipids than those without HCV; a similar associa- (fats) and cholesterol are also associated tion was not seen in people under age 40. with Type 2 diabetes. Another risk factor is There was no association between HCV and family history; if you have a parent or sib- Type 1 diabetes, nor between hepatitis B vi- ling with Type 2 diabetes, there is a greater rus (HBV) infection and either type of dia- chance that you will also develop the dis- betes. ease. Several hypothesis have been put forth to explain Type 2 diabetes appears to be HCV and Type 2 Diabetes more common in people with HCV. Two In the mid-1990s, researchers began to re- early suggestions were that people with dia- port that rates of Type 2 diabetes were betes might have been more likely to con- higher in people with hepatitis C virus tract HCV due to frequent medical proce- (HCV) infection, and vice versa. For exam- (Continued on page 3) Hepatitis C Support Project 2 HCV Advocate
  3. 3. (Continued from page 2) levels in overweight people, might impede dures, and that since people with Type 2 the action of insulin. diabetes often have elevated liver enzyme Insulin resistance may precede the de- levels, they might have been more often velopment of Type 2 diabetes. Some studies tested for HCV. However, studies that have suggest that diet and exercise modification controlled for these factors have still shown and early treatment with antidiabetic drugs increased rates of diabetes in people with can help prevent or delay the development HCV, leading researchers to suggest that of full-blown diabetes. However, the body’s HCV itself may contribute to diabetes. One ability to produce insulin may diminish over possibility is that HCV may infect and dam- time in people with insulin resistance, so the age the insulin-producing beta cells of the condition may progressively worsen. pancreas. Since HCV is known to be associ- ated with autoimmune conditions, another Symptoms of Types 2 Diabetes possibility is that the immune systems of people with HCV may attack and damage The symptoms of Type 2 diabetes typically insulin-producing cells. In addition, liver develop slowly over time (that is, it is a inflammation or damage due to HCV may chronic rather than an acute condition). affect the production of glucose or the me- Some people with mild Type 2 diabetes tabolism of insulin by the liver, thus altering have no symptoms and may be unaware that blood sugar levels. Studies have shown that they have the condition. Symptoms of dia- cirrhosis of the liver, regardless of cause, betes may include increased hunger and increases the risk of insulin resistance, al- thirst, frequent urination, fatigue, blurred though it is not known why. James vision, and dry, itchy skin. Everhart, MD, has suggested that HCV may not cause Type 2 diabetes directly, but may Long-Term Complications of Diabetes Over time, high blood sugar levels can lead rather have a “permissive” effect, acting to serious damage to many parts of the with other factors to cause the condition. body, especially the blood vessels and Clearly more research is needed in this area. nerves. Long-term consequences of diabetes (both Type 1 and type 2) include heart dis- Insulin Resistance ease, atherosclerosis (hardening of the arter- In many people with Type 2 diabetes, mus- ies), stroke, kidney disease, diabetic neu- cle, fat, and liver cells do not use insulin ropathy (nerve damage), gastroparesis properly, a condition known as insulin re- (damage to nerves that control the emptying sistance. The cause of insulin resistance is of the stomach), diabetic retinopathy (eye not known, but scientists believe it may be damage that can lead to blindness), and gum related to defects or deficiencies in the disease. Blood vessel and nerve damage can cells’ insulin receptors, or problems with lead to a variety of problems, including tin- signaling inside the cell. Being overweight gling, pain, or numbness in the hands and is known to trigger insulin resistance. A re- feet, sexual dysfunction, and ulcers or sores cent study by Claire Steppan and colleagues that are slow to heal. Complications due to from the University of Pennsylvania pub- severe nerve damage sometimes necessitate lished in the January 18, 2001 issue of Na- amputation of the lower limbs. According to ture suggested that a recently discovered the NIDDK, diabetes is the most common hormone called resistin, which is secreted cause of blindness, kidney failure, and am- by fat cells and may be present at higher (Continued on page 4) Hepatitis C Support Project 3 HCV Advocate
  4. 4. (Continued from page 3) available, urine testing is no longer consid- putation in U.S. adults. ered a reliable way to monitor blood sugar levels. Diagnosing Type 2 Diabetes Various tests are used to diagnose diabetes. Managing Type 2 Diabetes The most common is the fasting plasma People with Type 2 diabetes can live long glucose test. In this test, the blood sugar and relatively symptom-free lives if they level is measured after a person has fasted take good care of their health and carefully (no food or beverages except water) for manage their disease. This involves diet eight hours. According to current American modification, exercise, regular blood glu- Diabetes Association standards, a fasting cose monitoring, and treatment which may plasma glucose level of over 126 mg/dL in- include oral medications or injected insulin. dicates diabetes (a normal level is 80-120 mg/dL). Diet and Exercise Another test is the oral glucose toler- A healthy diet and adequate exercise are the ance test. In this test, a person drinks a first steps in managing – and preventing -- sugar-water solution after fasting overnight, Type 2 diabetes. Just as being overweight and their plasma glucose level is measured can trigger Type 2 diabetes, weight loss can to determine if glucose levels rise and fall improve the condition. People with Type 2 normally; a glucose level of 200 mg/dL or diabetes should eat a balanced diet that is higher after two hours indicates diabetes. If low in fat, salt, and refined sugar, and high a person has symptoms such as excessive in complex carbohydrates; such a diet thirst or frequent urination, a diagnosis of should contain plenty of fruits, vegetables, diabetes may be made if a random non- and grains. Maintaining a healthy diet can fasting blood test reveals a glucose level of promote weight loss, keep blood glucose 200 mg/dL or higher. levels within a healthy range, and reduce Other tests are done to monitor the pro- the risk of cardiovascular disease. Your gress of diabetes. The hemoglobin A1c test doctor or a dietitian can help you develop a measures how much sugar adheres to red good personalized eating plan. blood cells, and is used to determine aver- Exercise can also help control weight age blood glucose levels over the course of and improve cardiovascular health; in addi- three months. A desirable hemoglobin A1c tion, studies suggest that regular exercise test result is 7% or lower. This laboratory can help the body use insulin more effi- test should be repeated every 3-6 months to ciently. The NIDDK recommends exercis- help determine if a person’s diabetes is un- ing three times per week for 30-45 minutes der ; however, it is not a substitute for regu- each session. Check with your doctor before lar home blood glucose monitoring. starting any new exercise plan. Finally, urine tests may also be used to Eating adds fuel to the body and usually diagnose and monitor diabetes. In people raises blood sugar levels, while exercise with uncontrolled diabetes, metabolic by- burns fuel and tends to lower blood glucose products called ketones are excreted in the levels. Maintaining an awareness of when urine when the body burns fat instead of and how much you eat and exercise can glucose for fuel; this usually occurs in peo- help you keep your blood sugar within a ple with Type 1 diabetes. Since simple and healthy range. It may be helpful to eat and reliable home blood tests are now widely (Continued on page 6) Hepatitis C Support Project 4 HCV Advocate
  5. 5. Diabetic Emergencies Insulin shock is caused by extreme low blood sugar (hypoglycemia) that occurs when a diabetic’s insulin level becomes too high. This can happen if a per- son injects too much insulin, misses a meal, or exercises too strenuously. An insu- lin reaction usually comes on quickly. Symptoms include hunger, mental confu- sion, irritability, rapid pulse, shakiness, weakness, sweating, pale skin, fatigue, seizures, and loss of unconsciousness. Insulin shock can be fatal. First aid for in- sulin shock is rapid administration of sugar. If the person is conscious, help them eat or drink something like hard candy, jam, honey, fruit juice, or non diet soda. Glucose tablets and gel are also available. Do not try to give food or drink to an unconscious person; however, glucose gel or honey can be applied directly to the inner lip or under the tongue of a person who is unable to swallow. If the person loses consciousness, call 911. Emergency personal can inject glucagon, a rapidly acting hormone that increases blood glucose levels. If symptoms don’t improve in 10-15 minutes, administer more sugar. Once acute symptoms are relieved, the per- son should eat a snack or meal that contains carbohydrates. Diabetic coma is a life-threatening condition associated with extreme high blood sugar (hyperglycemia). It occurs when the body lacks insulin and burns fat instead of glucose for fuel, releasing a ketones into the blood. A high level of ke- tones can alter the chemistry of the blood, a condition called ketoacidosis. Dan- gerous hyperglycemia may occur if a person lacks access to insulin or is ill; it al- most always occurs in people with Type 1 diabetes. Unlike an insulin reaction, symptoms of ketoacidosis usually come on slowly, sometimes over several hours or even days. Symptoms include nausea, vomiting, abdominal pain, weakness, drowsiness, dehydration (characterized by sunken eyes and dry mouth and skin), deep rapid breathing, and finally loss of consciousness. In addition, the person’s breath will often have a fruity or acetone smell. A person experiencing ketoacido- sis or diabetic coma needs immediate medical attention. Call 911 or take the per- son to an emergency room. Both extreme hypoglycemia and extreme hyperglycemia can lead to loss of consciousness. If you are unsure which condition a diabetic person is experienc- ing, treat for insulin shock, since this is a more immediate danger (and since such treatment will not make a person with hyperglycemia appreciably worse). If the person does not respond to first aid, call 911. If you have diabetes, wear a MedicAlert tag so you can be treated properly if you are unconscious. Inform your doctor if you experience either type of diabetic emergency. If these happen frequently, your insulin or medication dose may have to be adjusted. Hepatitis C Support Project 5 HCV Advocate
  6. 6. (Continued from page 4) ments are available that can keep the condi- exercise at similar times each day. Some tion under control and allow people with the doctors recommend several small meals disease to live a long and healthy life. over the course of the day instead of 2-3 Unlike people with Type 1 diabetes, large meals, to help keep blood sugar levels people with Type 2 diabetes usually pro- more consistent. Skipping meals, engaging duce some insulin. Thus, treatment is usu- in unusually prolonged or strenuous ally focused on helping the body use insulin exercise, and illness can all affect blood as efficiently as possible. As noted above, sugar levels. When exercising, keep a snack the first steps in controlling Type 2 diabetes or sports drink on hand in case your blood involve changes in diet and exercise levels. sugar level falls too low. In some cases, changes in diet and exercise alone – especially if they lead to weight Blood Glucose Monitoring loss – can control mild Type 2 diabetes. They key to managing diabetes is keeping a consistent, healthy blood glucose level. Oral Antidiabetic Drugs Therefore, it is important to test your blood sugar level regularly. To perform this sim- If diet and exercise changes are not suffi- ple test, draw a drop of blood using a sharp cient to keep blood glucose levels within a tool called a lancet. Place the blood on a healthy range, oral antidiabetic medications test strip, which will change color depend- are usually tried next. These medications ing on how much glucose the blood con- only work in people whose bodies produce tains. You can determine your glucose level some insulin (thus, they are not effective in by comparing the colors on your test strip to people with Type 1 diabetes). those on a color chart, or you can use a glu- There are several major types of drugs cose monitoring machine which reads the used to treat Type 2 diabetes. The oldest test strip. Be sure to properly dispose of class of drugs are called sulfonylureas. used lancets in an appropriate “sharps” con- These drugs stimulate the production of in- tainer. New noninvasive glucose monitors sulin and help the body use insulin more ef- that measure glucose levels through the skin ficiently. This category include chlorpropa- are currently being developed. mide (Diabinese), glimepiride (Amaryl), Your doctor may recommend that you glipizide (Glucotrol), glyburide (Micronase, test your blood sugar before and after eating Glynase), tolazamide (Tolinase), and tolbu- and exercising. This is especially important tamide (Orinase). These drugs are typically for people who are newly diagnosed and are taken once or twice per day immediately be- learning how to keep their blood sugar at a fore meals. healthy level. Regular testing can help your Metglitinides also stimulate the produc- doctor determine correct dosages for medi- tion of insulin by the pancreas. The only cation or insulin. Keeping daily records of currently used drug in this class is repag- your blood glucose test results -- and how linide (Prandin). This drug is taken before they are related to meals, exercise, illness, each meal. and symptoms – is an important step in Alpha-glucosidase inhibitors retard the keeping your diabetes under control. digestion of starches and certain sugars by blocking an enzyme. This causes a slower increase in blood sugar after eating. Drugs Treatment for Type 2 Diabetes in this class are acarbose (Precose) and Diabetes is a chronic manageable condition. (Continued on page 7) Although there is no cure, several treat- Hepatitis C Support Project 6 HCV Advocate
  7. 7. (Continued from page 6) (especially when the drug is first started), miglitol (Glyset). These drugs are taken and may worsen existing kidney problems; with the first bite of a meal. on the other hand, they may have the bene- Biguanides help lower blood glucose ficial effect of decreasing fat and cholesterol levels by decreasing the amount of sugar levels. Both sulfonylurea and biguanide produced by the liver. The only currently drugs can adversely interact with alcohol, used drug in this class is metformin causing gastrointestinal upset and skin (Glucophage). It is taken 2-3 times per day flushing and occasionally more serious ill- with meals. ness. Finally, thiazolidinediones (“glitazone”) Thiazolidinediones can cause liver dam- drugs make the body’s cells more sensitive age, indicated by elevated liver enzymes to insulin. These drugs include pioglitazone and symptoms such as nausea, abdominal (Actos) and rosiglitazone (Avandia). They pain, lack of appetite, fatigue, and jaundice. are typically taken once or twice per day One drug in this category, troglitazone with food. (Rezulin), was taken off the market last year Because the various antidiabetic drugs because it caused fatal liver failure. Because work differently, your doctor may prescribe of their potential adverse effect on the liver, a combination treatment regimen. Some- pioglitazone and rosiglitazone should be times an initial drug is tried first and other used with extreme caution in people with medications added if it does not work alone. HCV or other liver disease. Often doctors will try different combina- Antidiabetic drugs can interact with tions and dosages to find the regimen that drugs for other conditions, affecting how works best for you. well they work and potentially increasing Oral antidiabetic drugs alone do not side effects. Interactions with drugs used to work for everyone. Even if they reduce treat HCV have not been well studied. blood glucose levels somewhat, the drugs However, in a 1998 case report from Italy, a may not bring levels within the normal 29-year-old man with chronic HCV devel- range that is optimal for good health. Oral oped diabetes during treatment with inter- drugs are most effective in people who have feron, leading a researcher to speculate that recently developed Type 2 diabetes and in interferon may enhance autoimmune dam- those whose blood sugar levels are not too age to insulin-producing cells. Tell your far above normal. doctor about any drugs you are using, in- Like all drugs, oral antidiabetic medica- cluding over-the-counter (non-prescription) tions may cause side effects. Sulfonylurea medications, herbal remedies, and recrea- drugs can cause upset stomach, skin rash, tional drugs. and weight gain. Meglitinides may cause weight gain. Sulfonylurea and meglitinide Insulin drugs, which stimulate the production of in- In some people with Type 2 diabetes, oral sulin, can cause blood sugar levels to drop drugs do not adequately control blood sugar too low (hypoglycemia), potentially leading levels. In others, medications work for to insulin shock; this does not occur with awhile, but then stop working over time. the other drug classes. Alpha-glucosidase Studies have shown that in people with inhibitors can cause intestinal gas, bloating, Type 2 diabetes, the body’s ability to pro- and diarrhea (especially when the drug is duce insulin may decline with time. If oral first started). Biguanides may cause weak- medication alone is not adequate, people ness, fatigue, nausea and/or diarrhea (Continued on page 8) Hepatitis C Support Project 7 HCV Advocate
  8. 8. (Continued from page 7) live long and healthy lives if they educate with Type 2 diabetes must inject insulin, as themselves about their condition and take do people with Type 1 diabetes. Sometimes good care of their health. oral drugs and insulin are used together. The longer a person has type 2 diabetes, the Resources more likely he or she will need insulin in- jections. When people with Type 2 diabetes American Diabetes Association: have an infection or undergo surgery, or National Institute of Diabetes and Digestive and when women with Type 2 diabetes become Kidney Diseas es: pregnant, they may need to use insulin tem- diabetes/diabetes.htm (includes specific information porarily. for African-Americans, Latinos, Asian/Pacific Is- landers, and Native Americans) Because current formulations of insulin are broken down by the digestive system, Canadian Diabetes Association: they cannot be taken by mouth; attempts to Centers for Disease Control and Prevention: make an effective oral insulin have been un- derway for years. Some formulations of in- sulin work rapidly, while others are more Liz Highleyman ( is a freelance long-acting. People may inject insulin once medical writer and editor. She has a certificate in or twice a day, or may use a wearable pump public health from the Harvard School of Public that delivers a steady amount of insulin. Do Health. She has worked as an editor of the Bulletin not reuse or share injection needles, and dis- of Experimental Treatments for AIDS (BETA), pub- lished by the San Francisco AIDS Foundation, and pose of them safely in an appropriate as health editor for the Internet search engine Ask “sharps” container. Jeeves. Control is Key Copyright 2001—Hepatitis C Support Project / HCV Controlling your blood sugar level is the Advocate key to good health. Maintain a healthy Permission is granted and encouraged with credit to weight, eat right, and get adequate exercise. the Hepatitis C Support Project. Monitor your blood glucose regularly. Take antidiabetic drugs and/or insulin as directed. Try to eat and take medications at about the same time each day. Let your doctor know if you are having trouble maintaining a con- sistent, healthy blood sugar level. Poorly controlled diabetes is associated with numerous long-term complications. Have your blood pressure, kidney function, and vision checked regularly. Brush and floss your teeth daily, and get regular dental checkups and cleanings. Avoid smoking to reduce the risk of cardiovascular disease. Learn about proper foot and skin care, which are especially important for people with diabetes. Make sure to inform your healthcare providers about any unusual symptoms. People with Type 2 diabetes can Hepatitis C Support Project 8 HCV Advocate