Chapter Two - Micronutrient Status in Type 2 Diabetes: A Review
Introduction
Diabetes mellitus is one of the leading chronic diseases in the world with the number of diabetics and prediabetics increasing rapidly due to population growth, aging, urbanization, increasing prevalence of obesity, and physical inactivity (Wild, Roglic, Green, Sicree, & King, 2004). Type 2 diabetes is the most common form accounting for approximately 90% of all diabetes cases. The hallmark features in the pathogenesis of type 2 diabetes are insulin resistance and inability of the pancreas to produce sufficient quantities of insulin to maintain normoglycemia. There is also depletion of the cellular antioxidant defence system secondary to increased oxidative stress resulting from hyperglycemia and hyperinsulinemia. Type 2 diabetes is characterized by an increased risk for the development of macrovascular disease and microvascular complications (retinopathy, neuropathy, and nephropathy).
Nutritional management of type 2 diabetes mellitus has concentrated on macronutrient intakes. But evidence has shown that micronutrient intake is important in promoting optimum health for diabetic patients especially when they are essential cofactors in glucose metabolic pathways, pancreatic β-cell function, and in the insulin signaling cascade (Bhanot, Thompson, & McNeill, 1994).
Alterations in micronutrient status in diabetes mellitus have been well established in human and animal trials (Mooradian and Morley, 1987, Rossetti et al., 1990). Lower plasma concentrations and higher urinary excretion of certain micronutrients have been reported in type 2 diabetics compared to healthy controls (Ma et al., 1995, Nadler et al., 1992). Some of these changes in micronutrient levels in the body appear to have a negative impact on glucose homeostasis and insulin sensitivity in type 2 diabetics and sometimes leading to complications of the disease. Therefore, a significant volume of research has looked at the effects of micronutrient supplementation on markers of glycemic control to quantify the magnitude of response to supplementation. Many of these studies seem to conclusively show a link between micronutrients and glucose homeostasis.
Type 2 diabetes is a multifactorial metabolic disorder characterized by chronic hyperglycemia due to relative or absolute lack of endogenous insulin (Sena, Bento, Pereira, & Seica, 2010). Type 2 diabetes patients have elevated fasting and postprandial plasma glucose levels. Defects in insulin action and secretion result in high blood glucose concentrations due to the β-cells’ inability to remove glucose from the bloodstream. Diabetes mellitus is characterized by excessive thirst, increased hunger, poor wound healing, and increased fluid losses due to excessive urine production (WHO, 2011). Patients with diabetes mellitus may also experience excessive sweating during attacks of hypoglycemia (Leung, Chan, & Choi, 1999). These symptoms where fluid losses occur could result in fluid deficit averaging 6 l or more in diabetic adults (Chiasson et al., 2003, Ennis, 1994, Kitabchi et al., 2001). Significant fluid losses from the body contribute to increased nutrient losses in diabetics. Diabetes mellitus can also affect protein metabolism which in turn is highly influenced by the presence of insulin (Tessari et al., 2011). Insulin is a key regulator of the response to nutrient intake in achieving net protein retention. Defects in the regulation of insulin by protein metabolism in type 2 diabetes may lead to changes in body tissue composition, metabolic rates, individual amino acid metabolic steps, and nutrient status. Altered protein metabolism and increased fluid losses in diabetes result in elevated excretion of micronutrients in the urine and reduced plasma micronutrient levels (Fig. 2.1).
With the homeostasis of micronutrients being disrupted due to diabetes, there is an increased metabolic demand for them. A growing body of interest has looked at the beneficial role of micronutrients in glycemic control in type 2 diabetics. In this review, the current status of knowledge on the micronutrients status in type 2 diabetics is characterized and the effect of micronutrient supplementation on glycemic control in diabetics is summarized.
Section snippets
Micronutrient metabolism in diabetes mellitus
Micronutrients are required in small quantities for specific functions in the body. They enhance insulin action through activating insulin receptor sites, serve as cofactors or components for enzyme systems involved in glucose metabolism, increase insulin sensitivity, and act antioxidants to prevent tissue oxidation (O'Connell, 2001). Chronic hyperglycemia causes significant alterations in the status of micronutrients in the body (Mooradian, Failla, Hoogwerf, Maryniuk, & Wylie-Rosett, 1994).
Conclusions
The studies reviewed in this chapter affirms that there is a considerable body of evidence showing the effects of micronutrients in glycemic control in type 2 diabetes. Although there is good evidence for an increased excretion of micronutrients in type 2 diabetics, it is hard to ascertain how the deficiency may influence the progression of type 2 diabetes. Even as patients may be treated with well-established hypoglycemic agents, studying alternative treatment options to improve insulin
Acknowledgments
This review was initiated by collaborating with D. S. M. The contents of the review are, however, solely that of the authors.
The authors are grateful to the Singapore Institute for Clinical Sciences for facilitating this chapter.
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