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Diabetic Instability 

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Glucose Meter Reading Showing Hypoglycemia. Courtesy Abbott.

Glucose Meter Reading.Courtesy Abbott.

What Is Diabetic Instability?

Diabetic instability, also called brittle diabetes, is poor control of blood sugar characterized by frequent rise (hyperglycemia) and fall (hypoglycemia). These fluctuations can be life-threatening and cause unnecessary complications.

Q: What are complications in diabetes?

A: Complications of diabetes include any/all of the following:

  • Peripheral neuropathy that causes burning, numbness, or tingling in the extremities.
  • Skin infections and ulcers that do not heal and can lead to amputation of toes, feet or legs.
  • Damage to retina that can progress to blindness.
  • Cataracts and glaucoma that impair vision and can cause blindness.
  • Increased susceptibility to serious infections of the genitourinary tract, lung and upper respiratory tract that can become systemic and life-threatening.
  • Kidney disease that can lead to kidney failure.
  • Heart disease that can lead to heart failure.
  • Vascular disease that can lead to stroke.
  • Impaired motility in digestive tract that can lead to dyspepsia and constipation.
  • Pregnancy complications.
  • Shortened life expectancy.

The main causes of brittleness include malabsorption, certain drugs (alcohol, antipsychotics), defective insulin absorption or degradation, defect of hyperglycemic hormones especially glucocorticoid and glucagon, and above all delayed gastric emptying as a result of autonomic neuropathy.1

What Is Diabetic Instability In Celiac Disease and/or Gluten Sensitivity?

  • Diabetic instability is a severe non-gastrointestinal presentation of gluten sensitive enteropathy characterized by fluctuation in blood glucose level.2 In this situation, absorption of nutrients could be variable or overt malabsorption could occur, altering insulin requirements and affecting diabetic control.
  • Improvement in diabetic control and a decrease in hypoglycemic episodes have been demonstrated in children with celiac disease and type 1 diabetes mellitus after institution of a gluten free diet.3
  • A case-control study investigating 1000 patients with type 1 diabetes aged older than 16 years who were assessed for celiac disease against matched control subjects found that adults with undetected celiac disease and type 1 diabetes have worse glycemic control.4

How Prevalent Is Diabetic Instability In Celiac Disease and/or Gluten Sensitivity?

Diabetic instability has increased frequency in patients with untreated celiac disease.3

What Are The Symptoms Of Diabetic Instability?

  • Diabetic instability is marked by difficulty controlling blood glucose level.

How Does Diabetic Instability Develop In Celiac Disease and/or Gluten Sensitivity?

  • Diabetic instability results from impaired digestion of meals resulting from malabsorption in celiac disease including carbohydrate, protein, fat, chromium, and B vitamins.5
  • Inflammation from gluten enteropathy may interfere with the absorption of oral diabetic medications which in turn affect blood sugar control. Elevated blood sugar may result because there is not enough or a timely dose available.
  • Delayed gastric emptying increases the time it takes for food to get into the bloodstream. The effect of diabetic medicine, either oral or injection, is to reduce blood glucose. However, if food is not digested to reach the bloodstream when the medicine takes effect, the result will be hypoglycemia.

Does Diabetic Instability Respond To Gluten-Free Diet?

Yes. Celiac disease-related diabetic instability responds to gluten free diet.3

6 Steps To Improve Diabetic Instability In Celiac Disease and/or Gluten Sensitivity:

Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both diabetic instability and gut health.

  • Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
  • A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
  • Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

  • Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
  • Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.6
  • The intestinal lining may take up to a year to heal.
  • 2 Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

Here Are Major Inflammatory Food Types That Reduce Healing:

  • Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.7
  • Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
  • Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.7
  • Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.7.
  • Excessive Refined White Flours (bran layer removed)Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.7
  • Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
  • Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.7
  • Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.7

Here Are Important Anti-Inflammatory Food Types to Promote Health:

  • Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
  • Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
  • High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
  • Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
  • Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
  • Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
  • Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
  • Protective Herbs and Spices.  See below #6 below for examples.
  • 3 Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

  • 4 Manage Your Medications Safely:

Certain medications cause deficiencies of protein, chromium, and B vitamins that promote diabetic instability. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

ANTACIDS / ULCER MEDICATIONS

  • Pepcid®, Tagamet®, Zantac® deplete Chromium.
  • Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Chromium.
  • Alka Seltzer®, Baking Soda deplete Proteins.

ANTI-DEPRESSANTS

ANTIBIOTICS disrupt intestinal permeability which complicates celiac disease.

  • Gentomycin, Neomycin, Streptomycin, Cephalosporins, Penicillins deplete B Vitamins.
  •  Tetracyclines deplete Vitamin B6, Riboflavin.

ANTI-INFLAMMATORIES disrupt intestinal permeability which complicates celiac disease.

  • Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Vitamin B6, Vitamin B12, Folic Acid, Chromium.
  • NSAIDS (Motrin®, Aleve®, Advil®, Anaprox®, Dolobid®, Feldene®, Naprosyn® and others) deplete Folic acid.
  • Aspirin and Salicylates deplete Folic acid, Pantothenate (vitamin B5).

ANTICONVULSANTS

ANTIVIRAL AGENTS

  • Zidovudine (Retrovir®, AZT and other related drugs) deplete Vitamin B12.

CARDIOVASCULAR DRUGS

CHOLESTEROL DRUGS

DIABETIC DRUGS 

DIURETICS

FEMALE HORMONES disrupt intestinal permeability which complicate celiac disease.

MAJOR TRANQUILIZERS  

  • Thorazine®, Mellaril®, Prolixin®, Serentil® and others deplete Vitamin B12.

  • 5Nutritional Supplements To Help Correct Deficiencies:

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

  • 100% multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
  • B-Complex 100% to 300% or as prescribed.
  • Vitamin B12 as prescribed following blood test for status.
  • Chromium nicotinate as prescribed, but do not take at same time as calcium because they compete for absorption.

Storage NoteStore container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.

  • 6Manage Natural Remedies: 

Hydration:

  • Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
  • If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
  • Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
  • What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.

Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

  • Raspberry.
  • Carrot is also a cleansing digestive tonic.
  • Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
  • Redbeets also stimulate and improve digestion and are easily digested.
  • Cabbage also stimulates and improves digestion and is also a liver decongestant.
  • Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
  • Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

  • Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
  • Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
  • Parsley also relieves indigestion.
  • Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
  • Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

  • Cloves are also antispasmodic.
  • Nutmeg is also useful for indigestion.
  • Ginger.

Exercise Helps: Exercise improves circulation and rids the body of toxins.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal.

What Do Medical Research Studies Tell About Diabetic Instability In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

High prevalence of microvascular complications in adults with type 1 diabetes and newly diagnosed celiac disease.” This case-control study investigating 1000 patients with type 1 diabetes aged older than 16 years who were assessed for celiac disease against matched control subjects found that adults with undetected celiac disease and type 1 diabetes have worse glycemic control and a higher prevalence of retinopathy and nephropathy.

HbA1c, lipid profile, quality of life, retinopathy stage, nephropathy stage, and degree of neuropathy before and after 1 year on a gluten free diet were assessed in order to better understand the implications of celiac disease in adult patients with type 1 diabetes with respect to diabetes-related outcomes including glycemic control, lipids, microvascular complications, quality of life, and the effect of a gluten-free diet.

In this study, the prevalence of celiac disease was 33 per 1,000 subjects (3.3%). Compared with the population control group, in which the prevalence of celiac disease was 1% (12 of 1,200), there was an increased prevalence of celiac disease in people with type 1 diabetes. At diagnosis of celiac disease, adult type 1 diabetic patients had worse glycemic control (8.2 vs. 7.5%), lower total cholesterol (4.1 vs. 4.9%), lower HDL cholesterol (1.1 vs. 1.6%), and a higher prevalence of retinopathy (58.3 vs. 25), nephropathy (41.6 vs. 4.2%), and peripheral neuropathy (41.6 vs. 16.6%). There was no difference in quality of life. After 1 year on a gluten free diet, only the lipid profile improved overall, but in individuals who adhered to the gluten free diet HbA1c and markers for nephropathy improved. Treatment with a gluten free diet for 1 year is safe in adults with type 1 diabetes and does not have a negative impact on the quality of life.

Researchers state, “The mechanism by which celiac disease increases the risk of microvascular disease is unclear and is likely to be multifactorial. Unrecognized celiac disease is associated with raised homocysteine levels, which is probably a result of deficiency in folic acid and other B vitamins, which is a risk factor for endothelial dysfunction. In the current study, the combination of higher HbA1c and lower HDL cholesterol, possibly secondary to underlying chronic inflammation, may be the mechanism. Improvement of these parameters after 1 year on a gluten free diet is encouraging and similar to that seen in newly diagnosed celiac disease without diabetes.”4

CASE REPORT SUMMARIES

“Diabetic instability and celiac disease.” This case report describes a 47 woman with Type I Diabetes Mellitus and poor insulin control. Diagnosed at 30 years of age, the patient began having frequent and unpredictable hypoglycemia and hyperglycemia along with weight loss. Endoscopy and work-up for dyspepsia, which excluded diabetic gastroparesis, revealed celiac disease. Biopsy showed complete mucosal atrophy typical of severe enteropathy. Improvement of metabolic control was observed 6 months after beginning a gluten-free diet.8

  1. Vantyghem MC, Press M. Management strategies for brittle diabetes. Ann Endocrinol (Paris). 2006 Sep;67(4):287-96. []
  2. Murray JA, The widening spectrum of celiac disease. American Journal of Clinical Nutrition. Mar 1999;69 (3):354-365. []
  3. Book LS. Diagnosing celiac disease in 2002: who, why, and how? Pediatrics. May 2002;109(5):952,3p. [] [] []
  4. Leeds JS, Hopper AD, Hadjivassiliou M, Tesfaye S, Sanders DS. High prevalence of microvascular complications in adults with type 1 diabetes and newlydiagnosed celiac disease. Diabetes Care. 2011 Oct;34(10):2158-63. doi: 10.2337/dc11-0149. [] []
  5. Book LS. Diagnosing celiac disease in 2002: who, why, and how? Pediatrics. May 2002;109(5):952,3p. []
  6. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. []
  7. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [] [] [] [] [] []
  8. Levy J, Mathews D, Hermans M. Diabetic instability and celiac disease. Diabetes Care. Dec 1998; vol1(12):2192. []

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