A Practical Guide to a Healthy Body for People Living with HIV

 

Diabetes and Blood Sugar Problems

Normally, when we eat, our body converts food into glucose (sugar) and that glucose is then carried to cells throughout the body, providing our muscles, tissues and brain with the energy they need. If a person has too much blood glucose or blood sugar (a condition called hyperglycemia), it can eventually cause serious health problems. This is why it is so important to do as much as possible to avoid developing a blood sugar problem in the first place or, if you already have one, to take steps to manage it. Fortunately, diabetes can be controlled through eating well, exercise and medicine.

What are insulin resistance and diabetes?

Insulin is a hormone that your body needs to maintain the right level of glucose in your blood. When you don’t have enough insulin, or your body cannot use insulin properly, the amount of glucose in the blood becomes too high. This is called insulin resistance.

When insulin resistance first develops, your body tries to compensate by producing more and more insulin. But eventually, these efforts are unsuccessful and sugar levels build up in the blood instead of being used by your cells for energy. This ongoing high blood sugar is the hallmark of type 2 diabetes.

When a person has diabetes and their cells don’t get enough glucose, the cells cannot function properly. High blood glucose levels can also result in damage to the blood vessels in different parts of the body. Over time, this can lead to serious, and some potentially deadly, health problems—such as cardiovascular problems, kidney failure, blindness, nerve damage and digestive issues. These problems need advanced medical care.

There are three types of diabetes:

  • Gestational diabetes – diabetes that can develop during pregnancy.
  • Type 1 diabetes – an autoimmune disease that typically develops during childhood. It occurs when the body is unable to produce insulin.
  • Type 2 diabetes – a form of diabetes that usually affects middle-aged and older adults (although it can affect a person at any age). This is by far the most prevalent form of diabetes and the one we focus on in this chapter.

Risk factors for diabetes

A growing number of people living with HIV also have type 2 diabetes. This is due to some HIV-specific risk factors as well as some traditional risk factors, which affect both HIV-positive and HIV-negative people.

Certain HIV medications, especially some of the older ones, have been associated with a higher risk of diabetes:

  • some protease inhibitors, such as indinavir (Crixivan) and nelfinavir (Viracept)
  • some nucleoside analogues (nukes), such as AZT (zidovudine, Retrovir, also in Combivir and Trizivir), d4T (stavudine, Zerit) and ddI (didanosine, Videx EC)

HIV infection itself can increase a person’s risk for diabetes, especially if they have had HIV for many years, if they have a low CD4 count and a high viral load, or if they are co-infected with hepatitis C. Researchers have found that diabetes is more common among people who are co-infected with HIV and hep C than among people infected with only hep C.

Traditional risk factors include:

  • being overweight (especially if you have excess weight around the belly)
  • a family history of diabetes
  • being over the age of 40
  • lack of physical activity
  • hepatitis C infection
  • abnormal lipid levels, specifically low levels of “good” cholesterol (HDL) or high levels of triglycerides
  • a history of high blood pressure
  • the use of medications that can increase blood sugar levels (for example, human growth hormone, niacin, glucocorticoids and megestrol acetate [Megace])
  • being diagnosed with prediabetes
  • polycystic ovary syndrome
  • sleep apnea

Studies have shown that diabetes rates are also higher among people who have a low income and among people who are black, Hispanic, Aboriginal or Asian.

Because hepatitis C is a risk factor for type 2 diabetes, all people who are co-infected with HIV and hepatitis C should be screened for diabetes.

Diagnosing diabetes

These are the classic warning signs of diabetes to watch for:

  • excessive thirst that continues despite drinking lots of water
  • abnormal hunger
  • increased urination (both increased frequency and increased volume of urine)
  • fatigue or lack of energy
  • blurred vision
  • unexplained weight loss (even when a person eats substantial amounts of food)
  • wounds and bruises that are slow to heal
  • trouble getting or maintaining an erection
  • numbness or tingling in the hands and/or feet

Also, high blood sugar can make a person feel nauseous and throw up.

If you experience any of these symptoms, call your doctor. As part of your care, he or she may recommend one of the following tests.

Fasting blood sugar test

This blood test is done after you fast (don’t eat) for at least eight hours. Your doctor will tell you how long you need to fast for and how to prepare for the test.

If your blood sugar level is…

it is considered…

< 5.6 mmol/L

normal

5.6–6.0 mmol/L

potentially abnormal

6.1–6.9 mmol/L

prediabetes

≥ 7.0 mmol/L

diabetes

A fasting blood sugar level that is higher than normal but not high enough to be classified as full-blown diabetes is called prediabetes. People with prediabetes are at higher risk for heart disease and are five to six times more likely to develop diabetes, so it is a warning that you can take steps to control your blood sugar and prevent prediabetes from progressing. Many people with prediabetes will not go on to develop diabetes.
 

Hemoglobin (A1C) test

When blood sugar levels rise, some of the sugar combines with your hemoglobin (the substance in your red blood cells that carries oxygen). By measuring the amount of glucose attached to the hemoglobin, this test is used to estimate your average blood sugar level over the last two to three months.

If your A1C level is…

it is considered…

< 5.5%

normal

5.5%–5.9%

potentially abnormal

6.0%–6.4%

prediabetes, a sign that you are at increased risk for diabetes

≥ 6.5% on two separate tests

diabetes

A number of things can alter the results of this test. For example, anemia (low iron), pregnancy, kidney disease, liver disease and high cholesterol levels can all affect the accuracy of an A1C test and lead to an abnormal result.

Oral glucose tolerance test

This test is used to see how well your body is able to lower blood sugar. After fasting for eight hours, you will be given a drink that contains some glucose (usually 75 grams). A sample of your blood will be taken before you do this, and then again at regular intervals after you drink the solution. In all, the test can last for up to three hours.

Note that many medications can influence the results of an oral glucose tolerance test, including some antipsychotic medications (used to treat schizophrenia, bipolar disorder, depression and Alzheimer’s disease), beta-blockers, corticosteroids, estrogens, oral contraceptives (birth control pills) and thiazide diuretics. Be sure that the doctor testing you for diabetes knows about any medications you are taking that might affect the test results.

If the results of these tests are abnormal, your blood sugar levels may need to be monitored more frequently. Your healthcare provider may recommend that you do regular blood sugar testing. Meters that require a small amount of blood from a finger prick can be used at home. Testing can be done upon awakening, before and after meals, and at bedtime, to help establish how much your blood sugar varies throughout the day and in response to the food you eat. Your healthcare provider will discuss your monitoring and treatment plan with you.

Tips for managing your blood sugar levels

Although diabetes rates have been on the rise in Canada, the good news is that there are things you can do to prevent and manage diabetes.

If you take HIV drugs that have been associated with blood sugar problems, switching your HIV drugs may decrease the risk of diabetes. Research findings to date have been somewhat conflicting so we do not know what the ideal medications are. But there is some evidence that switching from a protease inhibitor that is associated with an increased risk for diabetes to either a non-nuke or another drug class that is not associated with blood sugar problems may lower the blood sugar levels of some people.

If you have elevated insulin or blood sugar levels, these are some steps you can take to lower your risk of developing diabetes:

  • Exercise regularly. If you’re just starting to exercise, try to do:
  • 10 minutes of aerobic exercise 4× per week; and
  • resistance exercise or weight training 2× per week.

If you already do some exercise, aim to do:

  • 2½ hours of moderate-to-vigorous aerobic exercise per week (that’s equal to a half-hour 5× per week); and
  • resistance exercise or weight training 3× per week.

The more you increase your muscle mass, the more you will improve the sensitivity of your body’s cells to insulin (insulin sensitivity) and the better your chances of controlling your diabetes.

  • Maintain a healthy weight. Obesity is a serious risk factor for type 2 diabetes. On the other hand, losing fat while gaining muscle can help improve blood sugar levels as well as other conditions such as high blood pressure and high cholesterol.
  • Limit your intake of sugar and refined carbohydrates by reducing the amount of white starchy foods, white sugar and flour, and alcohol you consume. Many people benefit from limiting carbohydrates until their blood sugar levels have been controlled and, if needed, excess weight has been lost. When you do eat carbohydrates, try to stick to those that are low on the glycemic index, which ranks how much a serving of food raises blood sugar levels. (To find out how specific foods rank on this scale, visit the Canadian Diabetes Association website at www.diabetes.ca and search for “glycemic index.”)

To lower your sugar intake, check food labels. Sugar, which is added to many processed foods, can also show up as glucose, fructose, corn syrup and maple syrup. Reading food labels can help you make healthy food choices. You might also want to make an appointment with a nutritionist or registered dietitian.

  • Eat more foods that are high in fibre (especially vegetables, legumes and fruit) and low in polyunsaturated fats. This can help improve your blood sugar levels. The Canadian Diabetes Association recommends that adults have 25 to 50 grams of fibre every day. If you aren’t getting enough fibre from your diet, you can take a fibre supplement, like one of the psyllium seed husk products that are widely available. Build up your intake slowly; starting with too much or increasing your intake too quickly can cause gas and bloating. To reduce your intake of polyunsaturated fats, found in most vegetable oils and in many prepared foods, it’s best to stick with monounsaturated fats such as olive oil.
  • Quit smoking. Because smoking cigarettes speeds up the long-term health complications that diabetes can cause, smoking cessation is a crucial part of managing diabetes.
  • If you have low testosterone, talk to your doctor about testosterone replacement therapy. In men, low levels of testosterone have been linked to insulin resistance.
  • Take a vitamin/mineral supplement that contains B complex vitamins (including B6), antioxidants (especially alpha-lipoic acid) and minerals (especially magnesium and chromium).
  • If you are diagnosed with hepatitis C, consider treatment. Treating chronic hepatitis C infection can improve a person’s blood sugar levels. (The newer hep C treatments are more effective and don’t cause the same side effects that older treatments caused.)
  • Have your blood pressure and cholesterol levels monitored. If your levels are high, you may need treatment for these conditions.
  • Have your blood sugar levels monitored regularly. If lifestyle changes or switching drugs are not enough to get your blood sugar under control, your doctor may recommend that you take an antidiabetic medication, such as metformin. Before starting a new medication, find out what the possible side effects and risks are. You’ll want to make sure that it doesn’t interact with your HIV meds. If you do take an antidiabetic medication, your healthcare provider should carefully monitor your blood sugar levels.

By monitoring and controlling your blood sugar level, you can potentially prevent diabetes. If you’ve already been diagnosed with diabetes, these steps can help you prevent serious complications so that you can live a full and healthy life.