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Recent health and nutrition information from Douglas Laboratories 2002
DIABETES: A NATIONWIDE EPIDEMIC
Fast Facts About Diabetes
Diabetes is becoming more widespread in the United States each year. Almost
• 1 million new cases each year in
everyone knows someone who has diabetes. An estimated 17 million people in the
United States, 6.2 percent of the population, have diabetes mellitus – a serious,
lifelong condition. Of those who are 20 years of age or older, 16.9 million or 8.6%
have diabetes. People age 65 years or older account for 7 million cases of diabetes
• In 1999, approximately 450,000
and represent 20.1 percent of all people in this age group. Fully one-third or about 5.9
million people have not yet been diagnosed and 11.1 million people have a confirmed
older. This figure represents about19 percent of all deaths in the U.S.
diagnosis of diabetes. Each year, about 1 million people age 20 and older are diag-
for people that are 25 years of age
nosed with diabetes. About 151,000 people less than 20 years of age have diabetes.
This represents 0.19 percent of all people in this age group. Approximately one in
• Diabetes was the sixth leading
every 400 to 500 children and adolescents has type 1 diabetes. Clinic-based reports
cause of death listed on U.S. deathcertificates in 1999.
and regional studies indicate that type 2 diabetes is becoming more common among
• Diabetes is the leading cause of
American Indian, African American, and Hispanic/Latino children and adolescents.
7.8 million. 8.3 percent of all men have diabetes.
• Diabetes is the leading cause of
9.1 million. 8.9 percent of all women have diabetes.
treated end-stage renal disease,accounting for 43 percent of
• Non-Hispanic whites:
11.4 million. 7.8 percent of all non-Hispanic whites
• Non-Hispanic blacks:
2.8 million. 13 percent of all non-Hispanic blacks have
amputations were performed eachyear among people with diabetes.
diabetes. On average, non-Hispanic blacks are two times more likely to have
diabetes than non-Hispanic whites of similar age.
• Hispanic/Latino Americans:
2 million. 10.2 percent of all Hispanic/Latino
Gestational Diabetes . . . . . . . . . . . . . . . . . . .page 4
Americans have diabetes. On average, Hispanic/Latino Americans are Insulin Resistance Syndrome and 1.9 times more likely to have diabetes than non-Hispanic whites of similar age.
Hyperinsulinemia . . . . . . . . . . . . . . . . . . . . .page 4
Impaired Glucose Tolerance . . . . . . . . . . . . . .page 5
Mexican Americans, the largest Hispanic/Latino subgroup, are two times more
Complications of Diabetes . . . . . . . . . . . . . . .page 5
likely to have diabetes than non-Hispanic whites of similar age. Similarly,
Preventive Measures . . . . . . . . . . . . . . . . . . .page 6
residents of Puerto Rico are two times more likely to have diagnosed diabetes
Laboratory Testing and Diagnosis . . . . . . . . . .page 7
than U.S. non-Hispanic whites. Sufficient data is not available to derive more
Traditional Medical Treatments . . . . . . . . . . . .page 7
Functional Medical Treatments . . . . . . . . . . .page 11
specific current estimates for other groups.
Alternative/Complementary Medical Treatments . . . . . . . . . . . . . . . . . . .page 13
continued on page 2
• American Indians and Alaska Natives who receive
U.S. Population (Men/Women) Affected By Diabetes
care from the Indian Health Service (IHS):
15.1 percent of American Indians and Alaska Natives
receiving care from IHS have diabetes. At the regional
level, diabetes is least common among Alaska Natives
(5.3 percent) and most common among American Indians
in the southeastern United States (25.7 percent) and in
certain tribes from the Southwest. On average, American
Indians and Alaska Natives are 2.6 times more likely to
have diabetes than non-Hispanic whites of similar age.
• Asian Americans and Native Hawaiian or other Pacific
Prevalence data for diabetes among Asian
Americans and Native Hawaiians or other Pacific
Islanders are limited. Some groups within these popula-
tions are at increased risk for diabetes. For example, data
Mortality from Diabetes
collected from 1996 to 2000 suggest that Native
In 1999, approximately 450,000 deaths occurred among
Hawaiians are 2.5 times more likely to have diagnosed
people with diabetes that were 25 years and older. This figure
diabetes than white residents of Hawaii of similar age.
represents about 19 percent of all deaths in the United States
• Overall, the risk for death among people with diabetes is
about two times that of people without diabetes. However,
the increased risk associated with diabetes is greater for
younger people (3.6 times for people 25 to 44 years of
Editor In Chief
. Andrew D. Halpner, Ph.D.
age versus 1.5 times for those 65 to 74 years old) and
. Michael Traficante
women (2.7 times for women 45 to 64 years old versus
• Diabetes was the sixth leading cause of death listed on
U.S. death certificates in 1999. This is based on the
68,399 death certificates in which diabetes was listed as
the underlying cause of death. Diabetes was listed as a
contributing cause of death on an additional 141,265
death certificates. However, many decedents with diabetes
Contact Us:NutriNews Inquiries
do not have the disease entered on their death certificate;
only about 35 to 40 percent have it listed anywhere on the
Phone: (412) 494-0122 • Fax: (412) 278-6804
certificate and only about 10 to 15 percent have it listed
Email: firstname.lastname@example.orgCanadian Inquiries
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High Risk Factors for Diabetes
View back issues of NutriNews online at www.douglaslabs.com
The experts suggest that adults 45 years and older be tested
for diabetes. If their blood glucose is normal at the first test, they
When we eat, the pancreas is supposed to automatically
should be tested at 3-year intervals. People under age produce the right amount of insulin to move glucose from blood
45 should be tested if they are at high risk for diabetes. These
into our cells. In people with diabetes, however, the pancreas
either produces little or no insulin (type 1), or the cells do not
• Being more than 20 percent above ideal body weight or
respond appropriately to the insulin that is produced (type 2).
having a body mass index (BMI) of greater than or equal
Glucose builds up in the blood, overflows into the urine, and
to 27. BMI is the ratio of weight in kilograms to height in
passes out of the body. Thus, the body loses its main source of
fuel even though the blood contains large amounts of glucose.
A relative lack of glucose going to the muscles results in fatigue,
• Having a mother, father, brother, or sister with diabetes.
which causes many to seek medical care. There are three main
• Being African American, Alaska Native, American
types of diabetes, they are: Type 1 Insulin Dependant Diabetes,
Indian, Asian American, Hispanic American, or Pacific
Type 2 Non-insulin Dependant Diabetes and Gestational
(Pregnancy) Diabetes. Of the three types, type 2 is by far the most
• Giving birth to a baby weighing more than 9 pounds or
common and the most amenable to comprehensive treatment.
Type 1 Diabetes
• Having blood pressure at or above 140/90 millimeters of
Type 1 diabetes was previously called insulin-dependent
diabetes mellitus (IDDM) or juvenile-onset diabetes. Type 1
• Having abnormal blood lipid levels, such as high density
diabetes develops when the body’s immune system destroys
lipoprotein (HDL) cholesterol less than 35 mg/dL or
pancreatic beta cells, the only cells in the body that make the
triglycerides greater than 250 mg/dL.
hormone insulin that regulates blood glucose. The pancreas
• Having abnormal glucose tolerance when previously then produces little or no insulin. Someone with type 1 diabetes
needs to take insulin daily to live. This form of diabetes usually
strikes children and young adults, who need several insulin
What is Diabetes?
injections a day or an insulin pump to survive. Type 1 diabetes
Diabetes mellitus is a group of diseases characterized may account for 5 to 10 percent of all diagnosed cases of
by high levels of blood glucose resulting from defects in insulin
diabetes. Risk factors for type 1 diabetes include autoimmune,
production, insulin action, or both. Diabetes can be associated
genetic, and environmental factors. Symptoms of type 1
with serious complications and premature death, but people
diabetes usually develop over a short period, although beta cell
with diabetes can take steps to control the disease and lower the
destruction can begin years earlier. Symptoms include
increased thirst and urination, constant hunger, weight loss,
Diabetes is a disorder of metabolism – the way our bodies
blurred vision, and extreme fatigue. If not diagnosed and
use digested food for growth and energy. Most of the food we
treated with insulin, a person can lapse into a life-threatening
eat is broken down into glucose, the form of sugar in the blood.
diabetic coma, also known as diabetic ketoacidosis.
Glucose is the main source of fuel for the body.
Type 2 Diabetes
After digestion, glucose passes into the bloodstream, where
The most common form of diabetes is type 2 diabetes. type
it is used by cells for growth and energy. For glucose to get into 2 diabetes was previously called non-insulin-dependent diabetescells, insulin must be present. Insulin is a hormone produced by
mellitus (NIDDM) or adult-onset diabetes. About 90 to 95 per-
the pancreas, a large gland behind the stomach.
cent of people with diabetes have type 2. This form of diabetes
usually develops in adults age 40 and older and is most
common in adults over age 55. A rapid increase in the younger
gestational diabetes, impaired glucose tolerance, physical
population is now being seen. What was once a traditional
inactivity, and race/ethnicity. African Americans, Hispanic/
“middle-age” onset disease has now infiltrated the young adult
Latino Americans, American Indians, and some Asian
and even the adolescent age group. This alarming increased
Americans and Pacific Islanders are at a particularly high risk
rate in younger patients has sparked the attention of the for type 2 diabetes. Type 2 diabetes is increasingly being
medical industry to actively begin educational outreach pro-
diagnosed in children and adolescents.
grams to increase awareness in both patients and providers.
About 80 percent of people with type 2 diabetes are over-
Gestational diabetes is a form of glucose intolerance that
weight. Type 2 diabetes is often part of a metabolic syndrome
is diagnosed in some women during pregnancy. Gestational
that includes obesity, elevated blood pressure, and high levels
diabetes occurs more frequently among African Americans,
of blood lipids. Unfortunately, as noted above, 25% of children
Hispanic/Latino Americans, and American Indians. It is also
and adolescents are now overweight and type 2 diabetes is
more common among obese women and women with a family
history of diabetes. During pregnancy, gestational diabetes
When type 2 diabetes is diagnosed, the pancreas is usually
requires treatment to normalize maternal blood glucose levels
producing enough insulin but the body cannot use the insulin
to avoid complications in the infant. Though it usually disap-
effectively, a condition called insulin resistance. The body senses
pears after delivery, the mother is at increased risk of getting
this lack of effectiveness and frequently increases its production
type 2 diabetes later in life. After pregnancy, 5 to 10 percent
of insulin erroneously to regulate elevated blood glucose levels.
of women with gestational diabetes are found to have type 2
After several years of overproduction, or hyperinsulinism, insulin
diabetes. Women who have had gestational diabetes have a
production decreases. The result is the same as for type 1 diabetes;
20 to 50 percent chance of developing diabetes in the next 5
glucose builds up in the blood and the body cannot make effi-
to10 years. Other specific types of diabetes result from specific
cient use of it as a main source of fuel. The excess genetic conditions (such as maturity-onset diabetes of youth),glucose in the blood stream is then converted to storage energy,
surgery, drugs, malnutrition, infections, and other illnesses.
i.e. fat. Via production of glycerides then triglycerides, excess
Such types may account for 1 to 5 percent of all diagnosed
glucose metabolites are sent to the adipocyte to be saved for a
rainy day – that frequently never comes for many patients.
Insulin Resistance Syndrome and Hyperinsulinemia
The symptoms of type 2 diabetes develop gradually. They
The term “insulin resistance” describes a condition of the
are not as sudden in onset as in type 1 diabetes. Some people
reduced sensitivity of a cell to the action of insulin. Insulin must
have no symptoms. Symptoms may include fatigue or nausea,
bind “effectively” to the cell receptor as one of the first steps in
frequent urination, unusual thirst, weight loss, blurred vision,
appropriate glucose metabolism. If insulin is less than effective
frequent infections, and slow healing of wounds or sores. Fully
at the receptor, glucose levels tend to rise signaling a “need” for
a third of diabetics are walking around undiagnosed by the
more insulin. The body responds by secreting excessive insulin,
best health care industry on the planet! In my opinion, the
at times reaching 4-5 times the expected physiologic level. This
screening parameters set forth by the American Diabetic
secondary hyperinsulinemia can have a deleterious effect on
Association are only fueling this missed opportunity to uncover
the pancreas as it tries in vain to keep up with this excessive
diabetes at the earliest stage. I will discuss my recommendations
demand. The pancreas begins to fail and sets the stage for type
for improved screening later in this newsletter.
2 diabetes. Eager physicians are quick to prescribe a first-
Type 2 diabetes is associated with older individuals (until
or second-generation diabetic medication, betting on the
recently), obesity, family history of diabetes, prior history of
pancreas to produce even more insulin and further hastening
death rates about 2 to 4 times higher than adults without diabetes.
the demise of the pancreas beta cells. This insulin resistance or
The risk for stroke is 2 to 4 times higher among
insensitivity leads to glucose intolerance and dysglycemia.
Insulin Resistance Syndrome (IRS) also referred to as Syndrome
High blood pressure –
About 73 percent of adults with
X or Metabolic Syndrome refers to a set of metabolic abnormalities.
diabetes have blood pressure greater than or equal to 130/80
IRS is associated with glucose intolerance, abnormally low HDL
mmHg or use prescription medications for hypertension.
(high density lipoprotein) cholesterol and/or high triglyceride
levels, high blood pressure and upper body obesity. All of these
Diabetes is the leading cause of new cases of
factors are independent risk factors for coronary heart disease
blindness among adults 20 to 74 years old. Diabetic retinopathy
(CHD). CHD develops from a direct effect of insulin that stimu-
causes from 12,000 to 24,000 new cases of blindness each year.
lates lipogenesis in arterial tissue and enhances the growth of
Kidney disease –
Diabetes is the leading cause of treated
arterial smooth muscle promoting atherosclerosis. Increased
end-stage renal disease, accounting for 43 percent of new
insulin levels decrease fibrinolysis, increasing the risk for coro-
cases. In 1999, 38,160 people with diabetes began treatment
nary thrombosis. Insulin also increases the hepatic production of
for end-stage renal disease, and a total of 114,478 people with
triglycerides and lowers production of HDL (good cholesterol).
diabetes underwent dialysis or kidney transplantation.
High blood pressure may also be caused from the elevated
Nervous system disease –
About 60 to 70 percent of peo-
insulin’s effect on renal sodium reabsorption. Weight loss is a
ple with diabetes have mild to severe forms of nervous system
major benefit to those with Insulin Resistance Syndrome. High
damage. The results of such damage include impaired sensa-
dose vitamin E has been reported to improve insulin resistance in
tion or pain in the feet or hands, slowed digestion of food in the
type 2 diabetic patients. Zinc, selenium and vitamin C have been stomach, carpal tunnel syndrome, and other nerve problems.
associated with decreasing oxidative stress in diabetic patients.
Severe forms of diabetic nerve disease are a major contributing
Impaired Glucose Tolerance
Impaired glucose tolerance (IGT) and impaired fasting
More than 60 percent of non-traumatic
glucose (IFG) are considered to be pre-diabetic conditions, and
lower-limb amputations in the United States occur among
studies suggest that they may be reversible. IGT results from
people with diabetes. From 1997 to 1999, about 82,000
Insulin resistance covered in the above section.
non-traumatic lower-limb amputations were performed each
IGT is a condition in which the blood glucose level is year among people with diabetes.
elevated (between 140 and 199 milligrams per deciliter or
Dental disease –
Periodontal or gum diseases are more
mg/dL in a 2-hour oral glucose tolerance test), but is not high
common among people with diabetes than among people with-
enough to be classified as diabetes.
out diabetes. Among young adults, those with diabetes are
IFG is a condition in which the fasting blood glucose level is
often at twice the risk of those without diabetes. Almost one third
elevated (between 110 and 125 mg/dL after an overnight fast),
of people with diabetes have severe periodontal diseases
but is not high enough to be classified as diabetes.
with loss of attachment of the gums to the teeth measuring
Among U.S. adults 40 to 74 years of age, 16 million (15.6
percent) have IGT and 10 million (9.7 percent) have IFG.
Complications of pregnancy –
Poorly controlled diabetes
before conception and during the first trimester of pregnancy can
Complications of Diabetes
cause major birth defects in 5 to 10 percent of pregnancies and
Heart disease –
The leading cause of diabetes-related
spontaneous abortions in 15 to 20 percent of pregnancies.
deaths is heart disease. Adults with diabetes have heart disease
Poorly controlled diabetes during the second and third
trimesters of pregnancy can result in excessively large babies,
Blood pressure control –
Controlling blood pressure can
posing a risk to the mother and the child.
reduce cardiovascular disease (heart disease and stroke) by
Other complications –
Uncontrolled diabetes often leads to
approximately 33 to 50 percent and can reduce microvascular
biochemical imbalances that can cause acute life-threatening
disease (eye, kidney, and nerve disease) by approximately
events, such as diabetic ketoacidosis and hyperosmolar (non-
33 percent. In general, for every 10 millimeters of mercury
ketotic) coma. People with diabetes are more susceptible to
(mmHg) reduction in systolic blood pressure, the risk for any
many other illnesses, and once they acquire these illnesses they
complication related to diabetes is reduced by 12 percent.
often have a worse prognosis than people without diabetes.
Control of blood lipids –
Improved control of cholesterol
For example, they are more likely to die with pneumonia or
and lipids (for example, HDL, LDL and triglycerides) can reduce
influenza than people who do not have diabetes.
cardiovascular complications by 20 to 50 percent.
Preventive care practices for eyes, kidneys, and feet –
Detection and treatment of diabetic eye disease with laser
Research studies in the United States and abroad have
therapy can reduce the development of severe vision loss by an
found that lifestyle changes can prevent or delay the onset of
estimated 50 to 60 percent. Comprehensive foot care programs
type 2 diabetes among high-risk adults. These studies included
can reduce amputation rates by 45 to 85 percent. Detection
people with IGT and other high-risk characteristics for developing
and treatment of early diabetic kidney disease can reduce the
diabetes. Lifestyle interventions included diet and moderate-
development of kidney failure by 30 to 70 percent.
intensity physical activity (such as walking for 2 1/2 hours eachweek). For both sexes and all age and racial and ethnic groups,
Appropriate nutritional supplementation –
the development of diabetes was reduced 40 to 60 percent adequate amounts of high grade nutritional supplements shown
during these studies that lasted 3 to 6 years.
to be of benefit in diabetes may help improve daily glucose
control, stabilize carbohydrate metabolism and prevent
Studies have also shown that medications have been further complications from diabetes due to the glycosylated end
successful in preventing diabetes in some population groups. In
products caused by elevated glucose levels.
the Diabetes Prevention Program, a large prevention study of
people at high risk for diabetes, people treated with the drug
Routine exercise – low glycemic index diet –
metformin reduced their risk of developing diabetes by 31 percent.
exercise directly helps improve glucose metabolism by increasing
Treatment with metformin was most effective among younger,
the activity of glucose transport protein, independent of the
heavier people (those 25 to 40 years of age who were 50 to 80
action of insulin. Combined with an appropriate low glycemic
pounds overweight) and less effective among older people diet, exercise has been shown to be nearly twice as effective as
and people who were not as overweight. There are no known
a leading anti-diabetic medication. A recent study was halted
methods to prevent type 1 diabetes. Several clinical trials are
prematurely due to the profound superior benefit of diet and
exercise over the prescription medication. It would behoove
practitioners and clinicians caring for diabetic patients not to
Glucose control –
Research studies in the United States and
underestimate the significant impact that diet and exercise has
abroad have found that improved glycemic control benefits
on diabetes morbidity. Too often health care providers neglect
people with either type 1 or type 2 diabetes. In general, for
this all important aspect of care and education. If you are not
every 1 percent reduction in results of A1C blood tests, the risk
proficient at providing a quality educational experience for
of developing microvascular diabetic complications (eye, your diabetic patients, please refer them to a facility that can
kidney, and nerve disease) is reduced by 40 percent.
implement this critical component of their total care plan.
Laboratory Testing and Diagnosis
The committee recommended that the OGTT not be used.
An American Diabetes Association expert committee has
Testing for Diabetes During Pregnancy
recommended a lower fasting plasma glucose (FPG) value to
The expert panel also suggested a change in the testing for
diagnose diabetes. The new FPG value is 126 milligrams per
diabetes during pregnancy, stating that women at low risk for
deciliter (mg/dL) or greater, rather than 140 mg/dL or greater.
gestational diabetes do not need to be tested. This low-risk
This recommendation was based on a review of the results of
more than 15 years of research. This research showed that a
fasting blood glucose of 126 mg/dL or greater is associated
with an increased risk of diabetes complications affecting the
eyes, nerves, and kidneys. When diagnosis was based on a
blood glucose value of 140 mg/dL or greater, these complica-
• Not members of a high-risk ethnic group
tions often developed before the diagnosis of diabetes. The
experts believe that earlier diagnosis and treatment can prevent
All women who are not in the low-risk category should be
or delay the costly and burdensome complications of diabetes.
tested for gestational diabetes during the 24th to 28th weeks of
pregnancy. The testing procedure requires drinking a glucose
The prior criteria for diagnosing diabetes relied heavily on
drink and measuring blood glucose one hour later. If the blood
performing an oral glucose tolerance test (OGTT). In this test,
glucose value is 140 mg/dL or greater, the woman should be
the person must come in fasting, drink a glucose syrup, and
have a blood sample taken 2 hours later. This complicated pro-
cedure made detection and diagnosis of diabetes a difficult and
Traditional Medical Treatments
cumbersome process, and the expert committee recommended
• In order to survive, people with type 1 diabetes must have
that it be eliminated from clinical use. The change to using fast-
insulin delivered by a pump or injections.
ing plasma glucose for determining the presence of diabetes
• Many people with type 2 diabetes can control their blood
will make detection and diagnosis of diabetes more routine. The
glucose by following a careful diet and exercise program,
fasting value can be easily obtained during routine physician
losing excess weight, and if needed taking oral
visits, in clinics at the place of employment, and other situations.
medication. It is important to strive to educate patients
Currently, about 5 to 6 million adults in the United States have
about the beneficial nutritional and physiological aspects
diabetes but do not know it. The simpler testing method of
of treatment. Many times these treatments are overlooked
measuring fasting glucose should help identify these people so
by the medical profession, or minimal time is spent on
these recommendations in lieu of writing a prescription
Diabetes can be detected by any of three positive tests. To
medication as a first line treatment.
confirm the diagnosis, there must be a second positive test on a
• Traditional physicians may treat people with diabetes with
several medications to control their cholesterol and blood
• A casual plasma glucose level (taken at any time of day)
pressure in an effort to prevent premature cardiac and
of 200 mg/dL or greater when the symptoms of diabetes
• Among adults with diagnosed diabetes, about 11 percent
• A fasting plasma glucose value of 126 mg/dL or greater.
take both insulin and oral medications, 22 percent take
• An OGTT value in the blood of 200 mg/dL or greater
insulin only, 49 percent take oral medications only, and
17 percent do not take either insulin or oral medications.
Insulin products available and defined according to derivation, onset*, peak, and duration** of action. Route of administration is also shown.
*Onset is always for the SC route. All times are approximate.
**Maximum occurs between these times; actual effect may last longer.
Insulins listed are available in a concentration of 100 Units/mL; Humulin R, in a concentration of 500 Units/mL for SC injection only, is available by prescription from Lilly for insulin
resistant patients who are hospitalized or under close medical supervision.
1Recombinant (using E. coli
2Recombinant (using S. cerevisiae
3Recombinant human insulin analogue (using E.coli
The various insulins and oral medications for type 2 generation sulfonylureas. Diabinase or chlorpropamide, was
diabetes are listed in the table titled “Insulins.”
one the newer sulfonylureas, which like its first-generation
Classes of diabetic medications
cousins, has some major drawbacks when treating diabetes.
This class has a tendency to put weight on patients and also
Physicians have five different “classes” of oral prescription
cause low blood sugar levels. Low blood sugar, called hypo-
drugs which can be used to treat type 2 diabetes and injectable
glycemia, occurs when the blood glucose falls below a certain
insulin. Several of these oral medications have just been recently
level and causes several symptoms. Signs of hypoglycemia
include mental confusion, dizziness, loss of consciousness and
others. This is precisely the opposite effect that we wish to see.
The long standing class of drugs, the sulfonylureas, have
We want people with diabetes to lose those unnecessary
been the mainstay of the oral medications for many years.
pounds, not accumulate more! Insulin has at times been necessary
Sulfonylureas have been used for the treatment of to treat patients with type 2 diabetes. Naturally, patients would
type 2 diabetes since the 1950’s. Acetohexamide (Dymelor),
not prefer this type of treatment due to the invasive nature of
Tolbutamide (Orinase) and Tolazamide (Tolinase) were all first-
daily injections, so the oral agents are more popular when they
work to lower blood glucose levels. The sulfonylureas also
drugs as they do not cause weight gain like the sulfonylureas,
increase insulin levels by directly stimulating release. There are
nor do they increase cardiovascular risk profiles. Metformin
currently seven of them to choose from, of which the latest three
causes the liver and the muscle to utilize glucose better. In the
to come to market are called “second generation” sulfony-
muscles, metformin causes glucose to get into the cells more
lureas. These latest “offspring” are glyburide (Micronase,
easily to be metabolized. It also causes the liver to slow down
Glynase and Diabeta), glipizide (Glucotrol, Glucotrol XL) and
production of glucose. Glucophage was introduced in the spring
the youngest brother glimepiride (Amaryl). Sulfonylureas of 1995 and has been shown to lower triglyceride levels, as well
stimulate more insulin release, however many times the insulin
as total and LDL cholesterol levels. It also causes a rise in the
levels are already elevated, thus compounding the problems
good cholesterol levels (HDL cholesterol) with a slight loss
that are associated with increased insulin levels.
The newer prescriptions for type 2 diabetes are:
The benefits of this medication however have their costs.
Acarbose (Precrose) an [alpha-glucosidase inhibitor]
People taking the medication report bloating, nausea, cramps,
abdominal fullness and diarrhea as the unpleasant side effects.
The alpha-glucosidase inhibitors such as Acarbose are best
They do, however, usually go away after several days. Patients
used to treat the elevated glucose levels which occur after with kidney problems or congestive heart failure are not to take
eating in diabetic patients. This medication is better for this medication, nor are any patients with liver problems.
carbohydrate intolerance and is better than sulfonylureas which
Alcohol and binge drinking are not to be mixed with metformin.
can promote a rapid drop in glucose levels causing low blood
It should not be taken within 48 hours after any tests which use
sugar and magnify other medical problems. This drug was
iodine as the contrast material such as an IVP or CT scan.
released for use in 1996 but was used prior to this in Canada
and in Europe. Glyset is the newest of the AGI’s.
Troglitazone (Rezulin) a [thiazolidinedione]
Ascarbose interferes with an enzyme called alpha-
One of the newest medications for diabetes is a thiazo-
glucosidase in the small intestine. This enzyme is responsible for
lidinedione called Troglitazone or Rezulin, which was taken off
breaking down various ingested sugars in the small intestine. If
the market just after its debut. This medication was the first
they are not able to be broken down, they cannot be absorbed
medication which worked directly on insulin resistance. Rezulin
and the blood glucose level is less likely to rise abnormally after
increases the effect of insulin, but not the actual release of the
eating. This blocks glucose uptake from the small intestine but
hormone. The term “insulin sensitizer” has been used in the
carries with it some pretty unfriendly side effects. Excessive literature to describe how it works. The medication causes
gas and flatulence, diarrhea and abdominal pain make it a
glucose to be metabolized through the muscle when insulin is
questionable drug to use without the fear of a social “accident.”
effective. A side effect of this medication is that it may increase
Elevated liver function test can also occur with Ascarbose.
cholesterol levels and may cause severe liver damage, which
Particular care must be taken as a hypoglycemic event must be
eventually caused the FDA to request its withdrawal from the
treated with oral tablets or gel due to the absorption blocking
market. Significant weight gain was also seen in patients
activity in the small intestine. Patients with inflammatory bowel
taking Rezulin with Glyburide. This pill was used in patients
problems, such as irritable bowel disease, ulcers and colitis
who have type 2 diabetes and are taking insulin. The benefit
should also refrain from this alternative treatment. Patients with and potential importance of this medication was that patients
kidney problems should also look elsewhere for type 2 medication.
taking insulin shots may be able to discontinue their insulin
when taking Troglitazone. Troglitazone is now unavailable and
Metformin (Glucophage) a [biguanide]
the newer thiazolidinediones (Avandia and Actos) hope to have
The biguanids, like metformin, are improved diabetic all the benefits with less side effects as their predecessor.
Repaglinide (Prandin) a [meglitinide]
also available for physicians to prescribe. The FDA is continually
Repaglinide (Prandin) is a benzoic acid derivative that is a
looking at newer agents which are under development. The
blood glucose lowering agent. It will be used as first line therapy
increased emphasis that the Diabetes Control and
by doctors in conjunction with diet and exercise. Diet and Complications Trial has placed on diabetes undoubtedly will
exercise can frequently improve diabetes symptoms dramatically,
stimulate more and more prescription drug development in the
however, it has always been fraught with frustration due to lack
area of oral treatments for diabetes mellitus.
of compliance of patients’ willingness to participate in an
The newer insulins have a faster time of action and help to
aggressive enough program to make a change. In some cases,
keep the after-meal glucose levels from rising too high. They are
repaglinide was used together with metformin to help keep
generally used in the type 1 diabetic but also have uses in the
blood glucose levels down to the normal range. Prandin causes
patient with type 2 diabetes. Somewhere around 29% of type 2
increased release of insulin by the beta cells. The insulin is
diabetics are treated with insulin. This is a sad fact since with
dependent on glucose and levels fall as the glucose levels go
adherence to diet, a good exercise routine and increased
down. It works very quickly, then just as quickly quits working to
knowledge of the mechanics of diabetes, insulin could be avoided.
minimize side effects. This has been shown to be particularly
Insulin tells the liver to stop producing glucose and start
useful in diabetic patients with kidney problems. Prandin mag-
using it. In addition, insulin tells the muscles to suck in glucose
nifies the normal response of increased insulin in response to
and start burning it for fuel. Insulin can also tell the fat cells to
eating a meal. As the glucose level rises after eating, insulin is
take in glucose, but this occurs to a lesser amount. Insulin
released and causes unlocking of the gates to the cells so dosage and timing will have profound effects on the blood glucose can go from the blood stream into the cell itself.
glucose levels. Too much and the blood glucose level falls and
Repaglinide is welcomed as it has minimal hypoglycemic side
hypoglycemia can occur. Too little insulin and there is not
effects. Weight gain has been associated with repaglinide, enough to drive the glucose into the cells that need it. Insulin cansimilar to the sulfonylureas. Other less common side effects
be used in type 2 diabetics with or without some of the oral
include lowering of platelets, lowering of white cells, and
medications. Usual doses of insulin are given two times a day,
increased liver enzymes. This medication is best taken three
morning and evening to try to keep the glucose levels at a near
times each day with meals. People with kidney or liver problems
normal range. Eating pushes up the glucose your body needs to
should refrain from using this medication.
deal with. Exercise burns up glucose and can cause hypo-
Benefits of the newer therapeutics
glycemia if too much insulin is given or too little food is eaten.
The biguanides (Metformin or Glucophage) are not associ-
The delicate balance between multiple factors, food intake, energy
ated with weight gain as are traditionally the sulfonylureas.
expenditure, medication dosages, illness, and stress all interact
Acarbose (Precose), which is an alpha-glcosidase inhibitor, to raise or lower the levels of glucose in the blood. What is
targets the after-eating increase in glucose or post-prandial
universally accepted, is that the more closely the blood glucose
hyperglycemia. Precose is particularly good in patients whose
levels stay in the normal range the less systemic effects diabetes
glucose levels increase rapidly after eating a meal high in will have. If close attention is paid to balancing energy output
carbohydrates. The combination therapeutics are of benefit to
with food intake, along with a nutritionally sound vitamin and
patients that are resistant to taking multiple medications as are
mineral intake, the type 2 diabetic patient will have a good
the newer extended release versions of the above medications.
chance of keeping the levels of glucose in the correct range.
Insulins, new and old – Lispro (Humalog)
Insulin has its side effects and that is why many diabetics are
motivated to avert the need for insulin injections.
A faster acting form of insulin called Lispro (Humalog) is Hypoglycemia, weight gain, and faster disease occurring in the
blood vessels are all potential side effects of insulin therapy. It
I personally prefer chromium polynicotinate for supplemen-
is clear that close supervision by a health care provider trained
tation in both diabetes and overweight patients. Recommended
in diabetes is essential when it comes to insulin treatment. Close
dosages are up to 1000 micrograms daily divided with meals
monitoring by self-administration of glucose testing is critical to
(200 mcg with breakfast, 400 mcg at lunch and 400 mcg at
follow the effects of the treatment.
dinner). These doses are sufficient to promote the 200 mcg
absorption that the body needs on a daily basis. The deficiency
Functional Medical Treatments
of chromium in the diet has lead some researchers to state
Alternative therapies are treatments that are neither widely
that we would need to consume in excess of 12,000 calories
taught in medical schools nor widely practiced in hospitals.
per day to get the required amount of chromium from dietary
Alternative treatments that have been studied to manage only sources.
diabetes include acupuncture, biofeedback, guided imagery,
Magnesium may alter both insulin secretion
and vitamin and mineral supplementation. The success of some
and the biological activity of insulin. Scientists believe that a
alternative treatments can be hard to measure. Critics of deficiency of magnesium interrupts insulin secretion in the pan-
natural-based therapies are quick to state that many alternative
creas and increases insulin resistance in the body’s tissues.
treatments remain either untested or unproven through Evidence suggests that a deficiency of magnesium may con-
traditional scientific studies, however many of these studies do
tribute to certain diabetes complications and co-morbidities
exist and are overlooked by those who do not desire to see a
such as insulin resistance, glucose intolerance and hyperinsu-
benefit exist. The traditional “double-blind” placebo controlled linemia. Low magnesium levels are associated with diabetic
clinical study relates a given single treatment to a specific
patients that have experienced diabetic ketoacidosis. In patients
desired outcome. Frequently, natural-based treatments require
with type 2 diabetes, research has demonstrated that
clinical descriptive studies for evaluation due to the nature of the
magnesium improves cellular uptake of glucose by insulin.
treatments’ effects on multiple organ systems and the overall
Vanadium is a compound found in tiny
amounts in plants and animals. Early studies showed that
In the early 1970’s, Dr. Walter Mertz, then
vanadium normalized blood glucose levels in animals with type
director of the US Department of Agriculture’s Human Nutrition
1 and type 2 diabetes. A recent study found that when people
Research Center, discovered that simple forms of chromium are
with diabetes were given vanadium, they developed a modest
poorly absorbed (typically less than 2% of the amount con-
increase in insulin sensitivity and were able to decrease their
sumed) and do not potentiate insulin activity like biologically
insulin requirements resulting in improved glucose levels.
active chromium. Dr. Mertz isolated a chromium compound
Although not completely understood, vanadium is thought to
from Brewer’s yeast that had a strong activating effect on
enhance the number of insulin receptors on cell membranes and
insulin. He discovered that this “active” chromium was com-
improve the binding of insulin to these receptors and/or
plexed with several amino acids and the B-vitamin niacin and
increase the glucose transport proteins within the cell
called this chromium complex: “Glucose Tolerance Factor” or
membrane. Improved utilization of glucose in the cells prevents
“GTF.” Dr. Mertz concluded that niacin was the key to chromium’s
excess glucose from being converted to triglycerides and
biological activity. Neither niacin by itself nor the common
ultimately stored as fat. Dosages of 10-100 mg. of Vanadyl
chromium picolinate complex had any significant effect on Sulfate have been shown to be beneficial in type 2 diabetes.
glucose metabolism. Dr. Mertz concluded that the niacin-bound
chromium, called “polynicotinate” or “nicotinate” was the
Garcinia Cambogia (Hydroxycitric Acid) –
biologically active form of chromium that potentiates Acid (HCA), the active ingredient in Garcinia Cambogia, is a
rare organic acid similar to the citric acid found in citrus fruits
such as oranges and lemons, but it has several unique proper-
Fenugreek is a compound that may improve
ties. HCA has been shown to reduce appetite and inhibit fat
glucose levels by decreasing the absorption of glucose by the small
production without stimulating the central nervous system like
intestine. It is thought that Fenugreek delays gastric emptying due
many of the OTC weight loss and prescription diet medications.
to its high level of soluble fiber. Fenugreek was also shown
HCA is extracted from the rind of the fruit of the Garcinia
to decrease both total cholesterol levels and triglyceride levels in
Cambogia tree where it has been used for seasonings and as a
diabetic patients. Defatted Fenugreek seed powder has been
food preservative by the people of Southeast Asia. HCA blocks
shown to produce a 25 percent drop in fasting blood glucose
a key enzyme responsible for the production of fat from leftover
measurements, 24 percent drop in elevated total cholesterol levels,
glucose that is not being used immediately for energy. When
32 percent decrease in LDL levels, and a 37 percent decrease in
carbohydrates are consumed they are broken down into glu-
cose and sent throughout the body. Excess glucose that is not
Biotin deficiency has been implicated in glucose
immediately needed for energy or metabolism is stored in the
intolerance and dysglycemia. Biotin has been shown to improve
body’s liver and muscles as glycogen. Glycogen can be rapidly
glucose metabolism without increasing the output of insulin from
utilized if needed from this storage depot in the liver and mus-
the pancreas. Biotin is thought to work via an increase in the
cle, but there is only so much room to store this “immediate
backup” form of energy fuel. The glucose in excess of that needed
B Vitamins –
Vitamin B6 is involved in inhibiting the
for liver and muscle glycogen storage is transformed into a
glycosylation of proteins known to cause tissue damage from
longer term depot of energy fuel (i.e. triglyceride and fat). The
excessive blood glucose levels and high tissue concentrations of
conversion of unused, or excessive glucose, is aided by an
glucose. B1 is involved with carbohydrate metabolism in the
enzyme called ATP-citrate lyase. HCA temporarily inhibits the
Krebs cycle and may prevent complications of diabetes like
activity of this enzyme thus decreasing fat production from carbo-
hydrate metabolism. In addition it promotes biochemical changes
in the liver that promote fat burning and glycogen storage.
Conjugated Linoleic Acid (CLA) –
Conjugated Linoleic Acid
or CLA has an effect similar to the prescription diabetic agents
Gymnema Sylvestre –
Gymnema Sylvestre is a compound
called thiazolidinediones. These compounds activate certain
that was shown to reduce glucose in the urine nearly 70 years
receptors that promote both glucose tolerance and lessen
ago. It was subsequently shown that Gymnema had a blood
glucose lowering effect when there was residual pancreatic
function, but had no affect on animals lacking pancreatic
Alpha-Lipoic Acid –
Alpha-Lipoic Acid has been demon-
function. Studies beginning again in 1981 showed that
strated to improve insulin sensitivity. The mechanism may be by
Gymnema lowered blood glucose levels and raised serum
increasing the activity of glucose transport proteins in patients
insulin levels during an oral glucose tolerance test. Further with type 2 diabetes.
studies revealed that Gymnema improved both glycosylated
Citrus Aurantium –
Citrus Aurantium is a member of the
hemoglobin and glycosylated plasma proteins, two indicators
citrus family frequently called “Orange Bitters.” The metabolic
of long term glucose control. Further studies in 1990 promoted
effect stems from an active alkaloid effect that stimulates the
the concept of beta cell repair/regeneration of the exocrine
sympathetic nervous system thus increasing metabolism.
pancreas as an effect of Gymnema causing an improved level
Omega-6 Fatty Acids –
Omega-6 Fatty Acids like black
of glucose homeostasis. Cholesterol levels, triglyceride levels
currant seed oil or evening primrose oil may aid in the reversal
and free fatty acid levels have all been shown to be lowered by
of nerve damage due to diabetic neuropathy.
Coenzyme Q10 –
CoQ10 or ubiquinone is a key compo-
transport and decreasing the requirements on insulin. Vanadyl
nent of the energy producing mitochondria, and is critical in the
Sulfate also aids in the synthesis of muscle mass and the ability
production of cellular energy known as ATP. The specific action
of CoQ10 and diabetes is not known, however, increased
Selenium is a trace element that works closely
metabolism via increased ATP production corresponds with with glutathione peroxidase and vitamin E to prevent damagea greater need for glucose as a substrate for cellular energy from free-radicals. Low levels of selenium are associated withproduction. A 36 - 59 percent positive response in diabetics has
poor immune function, acceleration of cardiovascular disease,
been reported with CoQ10 supplementation. Some have shown
and has been implicated in certain cancers.
that CoQ10 stimulates insulin production and has been shown
Zinc is a trace mineral involved in a majority of
to reduce fasting blood glucose levels and ketone bodies by enzymatic reactions throughout the body. Zinc is required for
proper activity and function of insulin and in the production of
Green Tea –
Green tea has been shown to increase insulin. It is believed that many people in the U.S. are at least
metabolism by increasing 24h Energy Expenditure (EE) and a
mildly zinc deficient, however severe zinc deficiency is very
decreasing the 24h Respiratory Quotient (RQ). Green tea has
rare. Poor wound healing and immune dysfunction is worri-
been demonstrated to significantly reduce food intake, body
some for diabetic patients and increased zinc intake can help
weight, blood cholesterol and triglycerides.
improve wound healing and promote effective immunity.
Folic Acid (Folate) –
Folate is involved in glucose metabolism
Vitamin C –
Vitamin C is transported into cells with the help
and is a critical factor in the metabolism of homocysteine.
of insulin. Insulin dysfunction can affect this transport and
Folate must be activated to 5-MTHF (5-Methyltetrahydrofolate)
a relative decrease in intracellular vitamin C can occur. Low
for effective action. Up to 25 percent of the population lack the
intracellular vitamin C levels have been implicated in poor
enzyme required for this activation and should take 5-MTHF
wound healing, dysfunctional immunity and increased capillary
permeability. Increased vitamin C intake in diabetic patients is
B-12 is involved in carbohydrate metabolism and recommended to offset these intracellular deficits.
is helpful in preventing and/or slowing the progression of
Manganese is used for activating enzymes
involved with glucose metabolism and is involved as a cofactor
Niacin is an essential component of Glucose
in a number of enzymes important in energy production and
Tolerance Factor (GTF), and its association with chromium is
antioxidant defense such as superoxide dismutase.
critical to effective insulin activity.
Alternative/Complementary Medical Treatments
Vitamin E –
Vitamin E has been shown to be helpful in
Acupuncture is a procedure in which a prac-
preventing complications of diabetes by preventing the titioner inserts needles into designated points on the skin. Some
oxidation of glycosylation products that cause tissue damage
Western scientists believe that acupuncture triggers the release of
throughout the body. Vitamin E has been associated with
the body’s natural painkillers. Acupuncture has been shown to
improving the flexibility of the cell membrane and increasing offer relief from chronic pain and is sometimes used by people
utilization of glucose. Vitamin E has also been recommended with neuropathy, the painful nerve damage caused by diabetes.
for preventing complications of diabetic retinopathy and
Biofeedback is a technique that helps a
person become more aware of and learn how to deal with the
Vanadyl Sulfate –
Vanadyl Sulfate improves and maintains
body’s response to pain. This alternative therapy emphasizes
proper blood glucose balance by increasing the rate of glucose
relaxation and stress-reduction techniques. Guided imagery is
a relaxation technique that some professionals use in biofeed-
• Demonstration that antihypertensive drugs called ACE
back. With guided imagery, a person thinks of peaceful mental
(angiotensin-converting enzyme) inhibitors prevent or
images, such as ocean waves. A person may also include the
delay kidney failure in people with diabetes.
images of controlling or curing a chronic disease, such as
• Promising results with islet transplantation for type 1
diabetes. People using this technique believe their condition can
diabetes reported by the University of Alberta in Canada.
A nationwide clinical trial funded by the NIH and the
Additional information on alternative therapies for diabetes
Juvenile Diabetes Research Foundation International is
To learn more about alternative therapies for diabetes
currently trying to replicate the Canadian studies.
treatment, contact the National Institute of Health’s Office of
• Evidence that people at high risk for type 2 diabetes can
Alternative Medicines Clearinghouse at (888) 644-6226. The
lower their chances of developing the disease through diet
National Diabetes Information Clearinghouse collects resource
information on diabetes for the Combined Health Information
• Evidence that high quality nutritional supplementation
Database (CHID). CHID is a database produced by health-
may augment various dysfunctional biochemical path-
related agencies of the Federal Government. This database
ways restoring them to a more homeostatic balance.
provides titles, abstracts, and availability information for health
information and health education resources.
Future Treatments for Diabetes
In the future, it may be possible to administer insulin through
Recent Advances in Diabetes Management
inhalers, a pill, or a patch. Devices are now available
In recent years, advances in diabetes research have led to
(GlucoWatch) that allow a 12 hour monitoring of glucose levels
better ways to manage diabetes and treat its complications.
through skin diffusion after a single daily calibration.
Researchers continue to search for the cause or causes of
• The development of a quick-acting insulin analog.
diabetes and ways to prevent and cure the disorder. Scientists
• Better ways to monitor blood glucose and for people with
are looking for genes that may be involved in type 1 or type 2
diabetes to check their own blood glucose levels.
diabetes. Some genetic markers for type 1 diabetes have been
• Development of external insulin pumps that deliver insulin
identified, and it is now possible to screen relatives of people
with type 1 diabetes to see if they are at risk.
• Laser treatment for diabetic eye disease that reduces the
The Diabetes Prevention Trial – Type 1 (DPT-1) identifies
relatives at risk for developing type 1 diabetes and treats
them with an oral form of insulin in the hope of preventing type 1
• Successful transplantation of kidneys and the pancreas in
diabetes. In the same study, researchers recently completed
people whose own kidneys fail because of diabetes.
a separate trial in which they found that low-dose insulin
• Better ways of managing diabetes in pregnant women,
injections do not prevent type 1 diabetes in relatives of people
thus improving chances of successful outcomes.
• New drugs to treat type 2 diabetes and better ways to
Transplantation of the pancreas or insulin-producing beta
manage this form of diabetes through weight control.
cells offers the best hope of cure for people with type 1
• Evidence that intensive management of blood glucose
diabetes. Some pancreas transplants have been successful.
reduces and may prevent development of diabetes However, people who have transplants must take powerful
drugs to prevent rejection of the transplanted organ. These drugs
are costly and may eventually cause other health problems.
Newer less immunogenic modifications are under development.
sity exercise, and lost 5 to 7 percent of their body weight.
Scientists are working to develop less harmful drugs and better
Participants randomized to treatment with metformin reduced
methods of transplanting beta cells to prevent rejection by the
their risk of getting type 2 diabetes by 31 percent.
body. Using techniques of bioengineering, researchers are also
Several new drugs have been developed to treat type 2
trying to create artificial beta cells that secrete insulin in response
diabetes. By using the oral diabetes medications now available,
to increased glucose levels in the blood.
many people can control blood glucose levels without insulin
In 1996, NIDDK launched its Diabetes Prevention Program
injections. Many people have been able to reduce their
(DPP). The goal of this research effort was to learn how to prescription medications, avoid prescription medications and
prevent or delay type 2 diabetes in people with impaired avoid insulin by using high grade nutritional supplements
glucose tolerance (IGT), a strong risk factor for type 2 diabetes.
designed for use in glucose dysfunction. Many patients are very
The findings of the DPP, which were released in August
fearful, and therefore quite motivated, of allowing their
2001, showed that people at high risk for type 2 diabetes could
condition to worsen to the point of needing insulin. I have
sharply lower their chances of developing the disease through
experienced a multitude of patients in my clinic that are drug
diet and exercise. In addition, treatment with the oral diabetes
free with sustained normalization of their Hgb-A1-C levels with
drug metformin also reduced diabetes risk, though less dramat-
appropriate daily supplementation and lifestyle modification.
ically. The same study was halted early due to the profound Studies are under way to determine how best to use nutritional
positive impact of diet and exercise versus metformin.
supplements, prescription medications and combinations of
Participants randomly assigned to intensive lifestyle intervention
both to manage type 2 diabetes. Medical intervention regarding
reduced their risk of getting type 2 diabetes by 58 percent. On
obesity and weight management is also a key factor in the
average, this group maintained their physical activity at 30
minutes per day, usually with walking or other moderate inten-
Did you know that EVERY 24 HOURS
Did you also know:
• 65% of people with diabetes die from heart disease
people are diagnosed with diabetes
• People with diabetes have the same cardiovas-
people die from diabetes
cular risk as if they had already had a heart attack
amputations are performed because
• Recent statistics show there are currently more than
people begin treatment for end-stage
• Centers for Disease Control estimate that by the
year 2050, the prevalence of diabetes will increaseby 165%
people lose their eyesight because
• Diabetes kills more people every year than AIDS or
breast cancer – one American dies from diabetesevery three minutes
References and Further Reading
Ornish, MD, Dean, Love & Survival: The Scientific Basis for the Healing Power ofIntimacy (HarperCollins 1997).
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Address by the Chief Executive Officer of the National Heritage Council Adv. Sonwabile Mancotywa at the Graduation CeremonyFort Hare University – AliceMay 12, 2011 Introduction My invitation here requested that I address myself on the subject of social cohesion and its relationship to heritage. Iguess the Office of the Vice-Chancellor would like me to answer the question: How do we harness
Duty to Warn “Sniper”: Lessons From Harry Chapin’s Classic School Shooter Song Brain-altering Psych Drugs as a Tipping Point to Overt Acts of Violence By Gary G. Kohls, MD I have been involved in the mental ill health industry in various ways since the early 1990s. In the last decade of my medical career I was an independent holistic mental health care practitioner. I found mysel