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Dear Joel:

How does smoking affect the release of insulin in your body? You write that
nicotine releases stored fat and sugar; this would make the insulin level
rise, of course, but I wonder if there isn't a more direct relation.

I tried to quit smoking many many times and never succeeded. This time, it
is extremely easy. I am quit for 8 1/2 days, cold turkey, of course, and
didn't have a single craving; I only experienced physical withdrawal.
Smoking is a memory of a former life already, it's so far away and I only
think of it because I am amazed that this quit is so easy.

I attribute this ease to two reasons:

I smoked additive-free tobacco these last years, so that my addiction was
really to tobacco and not to the chemicals the industry adds to it.

But more importantly, I think this quit is so easy because I switched to a
low carb diet a few months ago. This diet does me lots of good, and somehow,
I have a feeling that the quit is so easy because of my insulin being in
tune now and rather low than high.

Has anybody ever done any research on this?

Yours,

Iris

How to Maintain Glucose Levels

An extract from Natural Alternatives to Dieting

by Marilyn Glenville, Ph.D.

Almost all dieters have an underlying blood sugar imbalance. Blood sugar can be the most important factor in losing and maintaining a healthy weight. The importance of correcting blood sugar fluctuations to lose weight is emphasised by the title of an article published in the Encyclopaedia of Common Diseases written by the staff of Prevention Magazine; 'Low Blood Sugar Can Make You Fat'.

Blood sugar

Fluctuations in blood sugar can cause:
�?cravings
�?water retention
�?excess thirst
�?mood swings

Moods can swing from euphoric to unhappy; angry to couldn't care less; irritable and anxious to bored and tired. The positive moods can be as dangerous as the negative, because you are likely to swing rapidly from one extreme of mood to the other. You must take control of those highs and lows because the associated food cravings can undermine your efforts to change your eating patterns.

Perhaps you know that you are only overcome by cravings for sweet things at pre-menstrual times. If so, this chapter will later explain how blood sugar levels are connected with our hormones.

Nutrition and blood sugar

Nutrition is the key to stabilising the levels of blood sugar. After a meal, glucose from the breakdown of food (digestion) is absorbed through the wall of the intestine into the bloodstream. At this point, there is, quite naturally, a high level of glucose in the blood. The body takes what it immediately needs for energy and then produces insulin from the pancreas in an attempt to lower the level of excess glucose. Any glucose that is not used immediately for energy is changed into glycogen and stored in the liver and muscles to be used later. The glucose level in the blood then reduces to normal.

How do we maintain glucose levels? To maintain this balance in our blood sugar the body works in a similar way to the thermostat on a central heating system. Our natural 'thermostat' clicks into action as glucose levels rise and fall.

The body takes action in the following ways:

When the glucose levels fall too low

The hormone adrenaline is released from the adrenal glands and glucagon is produced from the pancreas. Glucagon works in the opposite way to insulin and increases blood glucose by encouraging the liver to turn some of its glycogen stores into glucose to give us quick energy. If the blood glucose level stays low for a period of time hypoglycaemia �?low blood sugar level �?can occur.

Symptoms include: irritability, aggressive outbursts, palpitations, forgetfulness, lack of sex drive, crying spells, dizziness, anxiety, confusion, forgetfulness, inability to concentrate, fatigue, insomnia, headaches, muscle cramps, excess sweating and excessive thirst.

Sounds familiar? Chances are that if you have a history of dieting then some or many of those symptoms are known to you. In themselves they can be burdensome, but more importantly they are the outward manifestations that your body is having trouble maintaining a good blood sugar level. They can certainly undermine the efforts of many dieters by triggering unhealthy eating which contributes to weight gain.

When the glucose level rises too high

Insulin is produced by the pancreas to lower it. If the blood sugar level remains too high, this causes the symptoms of hyperglycaemia �?high blood sugar level. The extreme form of this is diabetes which is a medical condition needing expert attention often entailing regular insulin injections. Weight cycling �?weight gain, loss then gain �?may make you more prone to diabetes. Obese people have a 77 times higher chance of developing diabetes than a person at their correct weight �?the greater your weight the higher the risk of developing diabetes.

During a normal day, the amount by which your blood sugar level rises and falls depends on what and when we eat:

What we eat or drink

When we eat any food in refined form its digestion is very fast. Refined foods have been stripped of their natural goodness by various manufacturing processes. Two of the most widely used refined foods are sugar and white flour. When digestion is too fast glucose enters the bloodstream too rapidly. This also happens when you eat any food or drink that causes a stimulant effect, like tea, coffee, sugar and chocolate. This sharp, fast rise in blood glucose makes you feel momentarily good but the 'high' quickly passes plummeting you to a low point, making you feel tired and drained. So what do you need? Another stimulant like a bar of chocolate or cup of coffee (or both!) to give you another boost.

The second boost will cause the blood sugar level to go up rapidly again and the vicious cycle is repeated. As blood sugar levels go up and down so too do our eating patterns with cravings for sweet foods and drinks.

Over time, this constant over-stimulation exhausts the pancreas. Then, instead of too much insulin, it produces too little. Too much glucose stays in the blood, causing the symptoms of high blood sugar levels.

You are advised to eat natural wholefoods which are unrefined and full of goodness. Their merits in terms of helping to maintain balanced blood sugar levels are discussed later in this chapter.

When we eat or drink

If there is a long gap between eating the blood glucose will drop to quite a low level and you will feel the need for a quick boost, say a cup of tea and a biscuit. At the same time, the adrenal glands will make the liver produce more glucose. The combination of these two acts causes high levels of glucose in the blood which again calls on the pancreas to over-produce insulin in order to reduce the glucose levels. The vicious cycle starts all over again and the adrenal glands become ever more exhausted.

To solve this problem try
�?Grazing �?develop a 'grazing' mentality to your eating patterns thus eating little but often. Leave behind the dieting philosophy of no food between meals.
�?Avoid skipped meals �?maybe you thought that if you ate less by missing meals you would lose weight but the resultant swings in blood sugar are setting you up to fail. They create a biological urge that must be satisfied and you shouldn't ignore your body's demands even if you were strong enough.

Make it easy for yourself. If you stop what is causing the biological urge then you won't be constantly at war with your own body.

Table 1: Vitamins for Weight Loss

Vitamin �?B2 (riboflavin)
Function �?Converts fat, sugar and protein into energy. For hair, nails and eyes.
Good sources �?Almonds, wild rice, soya beans, broccoli, wholemeal bread, mackerel, eggs, yoghurt.

Vitamin �?B3 (niacin)
Function �?Essential for energy production, balancing blood sugar, and maintaining cholesterol balance.
Good sources �?Canned tuna in oil, salmon, wholewheat, asparagus, almonds, brown rice

Vitamin �?B5 (pantothenic acid)
Function �?Involved in energy production and regulating fat metabolism.
Good sources �?Wholewheat, alfalfa sprouts, peas, lentils, eggs, mushrooms, brown rice.

Vitamin �?B6 (pyridoxine)
Function �?Aids digestion of protein, and helps maintain hormone balance. Useful for PMS and as an anti-depressant.
Good sources �?Brown rice, cauliflower, grilled herring, soya beans, sweet potatoes, sunflower seeds.

Vitamin �?C (ascorbic acid)
Function �?Required for collagen for healthy bones, skin, and muscles. Vital for immune function. Converts food into energy.
Good sources �?Raw peppers, broccoli, cauliflower, strawberries, peas, baked potatoes, oranges.

Vitamin �?Choline
Function �?Member of B complex family. Required for correct fat metabolism.
Good sources �?Eggs, cauliflower, cucumber, peanuts.

Vitamin �?Inositol
Function �?Works closely with choline. Aids fat transfer from liver.
Good sources �?Soya, eggs, citrus fruits, wholegrains, nuts.

Effects of adrenaline

If blood sugar levels are frequently low and our system is regularly being asked to pump out adrenaline then our health will suffer. Adrenaline is the hormone most of us associate with stress �?it is released for 'fight or flight' and its effect is very powerful. If you were threatened in the street, for example, or face any kind of physical danger your survival mechanisms would instantly step into action with the adrenal glands immediately producing large amounts of adrenaline.

The effects of adrenaline are
�?heart speeds up
�?arteries tighten to raise blood pressure �?hence a 'beating' heart
�?liver immediately releases emergency stores of glucose to give energy
�?digestion stops because it is not necessary for immediate survival
�?clotting ability of the blood is increased in case of injury.

This all means that you have been made ready to run faster, fight back and generally react more quickly than normal. Unfortunately, when your blood sugar level drops during the day or night, adrenaline is released automatically and the body experiences all the above sensations except that there is no outside stress to respond to. When this happens repeatedly, you can experience all the health problems outlined under the hypoglycaemia section earlier in this chapter. It can also contribute to heart disease by increasing the risk of blood clotting and higher blood pressure and the sudden release of glucose for energy can cause extreme fluctuations of sugar levels in the blood.

These fluctuations in blood sugar create an internal stress which the body then has to deal with. It causes an increase in sodium retention causing a bloated feeling from excess water. The digestive system will not function efficiently and less stomach acid will be produced which means that more food will actually be stored because it has not been digested sufficiently. The longer food stays in the intestines and remains undigested, the more calories are likely to be absorbed. It is therefore important that food is moved quickly out of the intestines.

Cravings and Binges �?What's the difference?

Cravings

Most dieters experience cravings to a lesser or greater degree. With some it is for chocolate, with others it is for biscuits and cakes. Certainly it is for sweet foods that most people crave although some dieters crave fats �?especially cream and hard cheese. Others, who don't usually have a drink problem, can find themselves craving a glass of alcohol. The sugar cravings are caused by the fluctuating blood sugar levels that we've just looked at. The other cravings could be caused by a food allergy or perhaps a yeast problem.

By and large you can control your own cravings, even those linked to the hormonal ups and downs of the menstrual cycle. It might be hard at first but by following the rules in this chapter you will find that with the passing of each successful day it will get easier and eventually the cravings will cease.

Binges

Binges can signal a more serious problem. Giving in to a craving and eating a bar of chocolate or several biscuits is not bingeing. A binge is eating for eating's sake, almost uncontrollably and even when you aren't hungry. Binge-ers have been known to grab at food with their hands rather than waste time with a knife and fork. There is a desperation about binge-ers who often binge in response to an emotional upset. Eating non-stop until you've finished a family-sized tub of ice cream, or a complete gateau, for example, is bingeing. So too is eating to the point of being sick. This is a long way from the normal cravings that most dieters experience.

Binge-ers will often feel physically and mentally ill after they've binged and it can be associated with psychological illnesses, like bulimia.
If you know that you binge, it is advisable to see your GP.

Eat plenty of unrefined complex carbohydrates including, wholewheat bread, wholemeal pasta, potatoes, brown rice, millet, oats, rye.

Eat fruit and drink diluted fruit juice.

Always eat breakfast �?porridge oats are good.

Eat small, frequent meals no more than three hours apart or five hours apart for men as their metabolism is slower.

Reduce, preferably avoid, stimulants including tea, coffee, chocolate, smoking and canned drinks that contain caffeine.

Consider taking one of the excellent food supplements on the market that can help balance your blood sugar while you are changing your eating patterns. See Table 1 above.

Develop the habit of reading labels carefully.

DON'T

Eat refined carbohydrates �?avoid 'white' in general. Remember that white flour is in many things like cakes, biscuits, pastries and white bread.

Eat sugar or the foods containing it �?including chocolate, sweets, biscuits, pastries, soft drinks.

Substitute decaffeinated coffee (as it contains two other stimulants, even when the caffeine is removed).

Eat convenience foods, they are likely to contain refined carbohydrates, sugar and high levels of fat and salt.

How can highs and lows be prevented?

There are three good ways:
1. Eat complex carbohydrates regularly
2. Avoid refined foods, especially sugar
3. Reduce foods and drinks that are stimulants

1. Eat complex carbohydrates regularly
To maintain well-balanced blood sugar levels eat foods such as complex carbohydrates that give a slow rise in blood sugar and keep a constant level for about three hours. Then eat again and prevent the level from dropping. Spacing food at three-hourly intervals in this way is a proven solution to the battle with cravings.

Dr Katharina Dalton, a pioneer in the recognition and treatment of pre-menstrual syndrome (PMS), has found that the symptoms of PMS can be relieved by eating regularly. This stops the blood sugar level from dropping and adrenaline from being released. While Dr. Dalton's findings have proved invaluable for PMS sufferers it serves to confirm the general theory that actually applies to all of us, including men.

Complex carbohydrates give a slow release of energy because it takes time for the digestive tract to break them down into simpler substances that the body can use. Carbohydrates are a large group of foods that includes sugars and starches. They are an important source of energy and the body breaks them down into the simple sugar, glucose. It is the slow speed with which this happens that is important to keeping blood sugar constant.

There are two types of carbohydrates:
Complex
�?Grains (wheat, rye, oats, rice, barley, maize)
�?Beans (lentils, kidney, chickpeas, aduki etc)
�?Vegetables, including potatoes
�?Fibre in grains, beans and vegetables

Simple
�?Fruit
�?Honey
�?White and brown sugar
�?Glucose in high-energy drinks

To help maintain a steady blood sugar level, aim to eat complex carbohydrates as part of your main meals and also as snacks during the day. You do not necessarily need to eat great amounts �?sometimes just an oat cake can be enough between meals to keep eating urges at bay.

If you find the symptoms associated with low blood sugar levels are greatest first thing in the morning or, you wake during the night, heart pounding and cannot get back to sleep, then it is very likely that your blood sugar level has dropped overnight and adrenaline has kicked into play. Eating a small, starchy snack, like an oat cake, one hour before going to bed and if possible, one hour after getting up, will help to alleviate these symptoms.

Make sure your complex carbohydrates are unrefined, which in general means choosing brown instead of white. For example, wholewheat bread, brown rice and wholemeal flour as opposed to the white versions which have been refined and therefore stripped of essential vitamins, minerals, trace elements and valuable fibre content. In order to digest these refined foods your body has to use its own vitamins and minerals, so depleting your own stores.

Fibre

It was originally thought that fibre's role was only to speed up the passage of food residues to prevent constipation. It is now known that some forms of fibre can actually slow down the absorption of sugars and help to maintain our blood sugar balance. Without fibre, food will affect the blood sugar level more quickly and it is harder to eliminate the food residues. The food stays in the body longer, which means that it absorbs more calories so preventing you from shedding those pounds.

Cravings and food allergies

If you experience cravings it's likely to be an indication that you suffer from blood sugar imbalance. They may also be symptoms of a food allergy, so this is worth checking. Ironically, if we are allergic to a particular food, we tend to crave it and eat it more. Ask yourself the question: "Which foods or drinks would I find it hard to give up?" The answer will give you a clue as to what to look out for

Shirley had been experiencing bad PMT symptoms and throughout the month would feel extremely hungry by about 5pm even though dinner was not until 6pm. We talked about her pattern of eating and she said that she was drinking up to eight mugs of tea a day. I explained the effects of drinks like tea and coffee on blood sugar balance and their link to PMT symptoms and advised her to gradually wean herself off drinks containing caffeine. Unfortunately, Shirley decided to cut out the eight mugs of tea straight away and rang me a couple of days later complaining of a bad headache and flu-like symptoms. Cutting caffeine out of your regime really must be done over a few days and it is best to begin by having half your drinks caffeinated and half de-caffeinated. Then over the next few days reduce the amount of caffeinated cups even further. Eventually you should cut out the de-caffeinated coffee because it still contains stimulants despite the absence of caffeine. Gradually introduce herb, fruit or grain tea so that you are still drinking the same amount of liquid. Once Shirley had taken the advised course of action it took her just a few days to feel a lot better. By the time I saw her two cycles later she was eating little and often and this pattern of eating had really helped with the PMT symptoms.

2. Avoid refined foods, especially sugar

The simple carbohydrates (with the exception of fruit) are all refined foods and should be avoided. Although fruit contains fructose (fruit sugar) which is a simple sugar, the fibre content of the fruit is a complex carbohydrate which slows the digestion rate. So fructose is acceptable when taken in the whole fruit, like an apple, but not when used in the refined form of powered white fructose, which is bought in boxes.

Pure fruit juice can also cause a rapid change in blood sugar levels because it is not buffered by the fibre that is normally present. It is better to dilute fruit juice in water to make it less concentrated.

Sugar sneaks unexpectedly into many foods. By the way, the brown-is-best theory doesn't apply to sugar, all colours do the same damage to your blood sugar balance! A can of cola may contain up to eight teaspoons of sugar as may a pot of fruit yogurt. Most of the convenience foods and drinks we buy are laden with sugar including savoury foods such as baked beans and mayonnaise. Did you know that tomato ketchup has just 8% less sugar, weight for weight, than ice cream and that the cream substitute for coffee is 65% sugar compared to 51% for a chocolate bar?

Sugar is an inexpensive bulking agent. Even some toothpastes contain sugar but as toothpaste is not a food, sugar does have to be included on the ingredients list.

When sugar is in its natural form �?the whole sugar cane �?it is fine to eat. It has all the right amounts of fibre and is a wholefood. When it is refined sugar is just 'empty' calories �?it contains no nutritional value so you can stop eating it and lose nothing but weight.

You may be tempted to substitute sugar with artificial sweetners �?DON'T! You are simply introducing an alien chemical which the body then has to deal with. Nobody really knows what havoc these chemicals can cause when introduced to the body's own delicately balanced biochemistry.

If a food or drink is described as 'low sugar' or 'diet' it will usually contain a chemical sweetner. These are also found in some non-diet crisps, ice lollies, sauces, pot noodles and some over-the-counter medicines. It's worth checking labels carefully.

3. Reduce foods and drinks that are stimulants

Sugar, smoking, caffeine in tea, coffee, chocolate and caffeinated soft drinks are all stimulants and cause a fast rise in blood sugar level followed by a quick drop which contributes to the roller-coaster ride of blood sugar swings. Avoid them whenever possible, even better, cut them out of your diet completely. Substitute them for example with herbal teas, grain coffee, spring water and diluted fruit juices.

Joel's Reinforcement Library

"Minimizing the Most Common

Side Effects to Quitting Smoking"

Blood sugar plummets in many people when first quitting. The most common side effects felt during the first three days can often be traced back to blood sugar issues. Symptoms such as headache, inability to concentrate, dizziness, time perception distortions, and the ubiquitous sweet tooth encountered by many, are often associated with this blood sugar drop. The symptoms of low blood sugar are basically the same symptoms as not having enough oxygen, similar to reactions experienced at high altitudes. The reason being the inadequate supply of sugar and/or oxygen means the brain is getting an incomplete fuel. If you have plenty of one and not enough of the other, your brain can not function at any form of optimal level. When you quit smoking, oxygen levels are often better than they have been in years, but with a limited supply of sugar it can't properly fuel your brain.
It is not that cigarettes put sugar into your blood stream; it is more of a drug interaction of the stimulant effect of nicotine that affects the blood sugar levels. Cigarettes cause the body to release its own stores of sugar and fat by a drug type of interaction. That is how it basically operated as an appetite suppressant, affecting the satiety centers of your hypothalamus. As far as for the sugar levels, nicotine in fact works much more efficiently than food. If you use food to elevate blood sugar levels, it literally takes up to 20 minutes from the time you chew and swallow the food before it is released to the blood, and thus the brain, for its desired effect of fueling your brain. Cigarettes, by working through a drug interaction causes the body to release it's own stores of sugar, but not in 20 minutes but usually in a matter of seconds. In a sense, your body has not had to release sugar on its own in years, you have done it by using nicotine's drug effect !
This is where many people really gorge themselves on food upon cessation. They start to experience a drop in blood sugar and instinctively reach for something sweet. Upon finishing the food, they still feel symptomatic. Of course they do, it takes them a minute or two to eat, but the blood sugar isn't boosted for another 18 minutes. Since they are not feeling immediately better, they eat a little more. They continue to consume more and more food, minute after minute until they finally they start to feel better. Again if they are waiting for the blood sugar to go up we are talking about 20 minutes after the first swallow. People can eat a lot of food in 20 minutes. But they begin to believe that this was the amount needed before feeling better. This can be repeated numerous times throughout the day thus causing a lot of calories being consumed and causing weight gain to become a real risk.
When you abruptly quit smoking, the body is in kind of a state of loss, not knowing how to work normally since it has not worked normally in such a long time. Usually by the third day, though, your body will readjust and release sugar as it is needed. Without eating any more your body will just figure out how to regulate blood sugar more efficiently.
You may find though that you do have to change dietary patterns to one that is more normal for you. Normal is not what it was as a smoker, but more what it was before you took up smoking with aging thrown in. Some people go until evening without eating while they are smokers. If they try the same routine as ex-smokers they will suffer side effects of low blood sugar. It is not that there is something wrong with them now, they were abnormal before for all practical purposes. This doesn't mean they should eat more food, but it may mean they need to redistribute the food eaten to a more spread out pattern so they are getting blood sugar doses throughout the day as nature really had always intended.
To minimize some of the real low blood sugar effects of the first few days it really can help to keep drinking juice throughout the day. After the fourth day though, this should no longer be necessary as your body should be able to release sugar stores if your diet is normalized. If you are having problems that are indicative of blood sugar issues beyond day three, it wouldn't hurt talking to your doctor and maybe getting some nutritional counseling. In order to allow your body to maintain permanent control over the amount of glucose (sugar) in your brain ... NEVER TAKE ANOTHER PUFF!

Joel

None of us EVER skipped breakfast

or lunch while still smoking nicotine!

Nicotine, via adrenaline releases pumped stored fats into our blood, ensuring that we were always well fed! It was a deadly means of eating.

If you try going without delivering fuel to your body after quitting nicotine, you are likely to experience one or more unnecessary withdrawal symptoms associated with low blood sugar. Nicotine is no longer feeding you and unless you adjust your normal food intake out more evenly over your entire day you could make withdrawal far more challenging than need be. What follows is a blood sugar symptoms article from WebMD

Hypoglycemia (Low Blood Sugar)

Symptoms

Hypoglycemia is not itself a disease but a condition that results from low blood sugar levels. The symptoms are not unique or specific to hypoglycemia; other conditions and illnesses have some of the same or similar symptoms. The symptoms a person experiences may vary from episode to episode and among different individuals. A doctor must carefully evaluate symptoms that may indicate hypoglycemia to be sure that some other condition is not causing them.

Low blood sugar can be mild, moderate, or severe. Increasingly severe symptoms appear as the blood glucose level falls. The most noticeable symptoms result from the effect of low blood sugar on the brain and nervous system.

Mild hypoglycemia

The initial symptoms appear as the body responds to the falling blood sugar levels by releasing glucagon, epinephrine (adrenaline), and other hormones. In normal individuals, blood glucose levels when fasting (between meals) are usually between 70 to 150 milligrams per deciliter (mg/dL).^{3, 4} The symptoms of mild low blood sugar usually develop when the blood sugar falls below 60 to 65 mg/dL. These may include:

Nausea; extreme hunger.
Feeling nervous or jittery.
Cold, clammy, wet skin; excessive sweating that is not caused by exercise.
A rapid heartbeat (tachycardia)
Numbness or tingling of the fingertips or lips.
Trembling.

Moderate hypoglycemia

If blood sugar levels continue to fall, the lack of adequate glucose begins to impair brain and nervous system functions. Additional symptoms appear that affect behavior and judgment. Symptoms usually develop when the blood sugar falls below 50 mg/dL. These may include:

Mood changes, such as irritability, anxiety, restlessness, or anger.
Confusion, difficulty in thinking, or inability to concentrate.
Blurred vision, dizziness, or headache.
Weakness, lack of energy.
Poor coordination.
Difficulty walking or talking, such as staggering or slurred speech.
Fatigue, lethargy, or drowsiness.

Note: A person experiencing moderate hypoglycemia may be too weak or confused to treat the low blood sugar and may need help.

Severe hypoglycemia

The symptoms of severe low blood sugar develop when blood sugar falls below 30 mg/dL. Symptoms may include:

Seizures or convulsions.
Loss of consciousness, coma.
Low body temperature (hypothermia).

Prolonged severe hypoglycemia can cause irreversible brain damage. If emergency medical treatment is not provided, severe hypoglycemia can be fatal. See the Topic Overview or Home Treatment section for links to information on emergency care for low blood sugar.

Note: The blood sugar levels given here are typical ones. However, actual measurements for normal blood sugar levels (euglycemia), and for mild, moderate and severe hypoglycemia, can vary from individual to individual. In some cases, symptoms may even occur when a person's blood sugar level makes a large drop from a high level into the normal range.

Some medications may interfere with whether symptoms of low blood sugar develop. These include beta-blockers, which are often used to treat heart conditions and high blood pressure.

http://my.webmd.com/encyclopedia/article/1667.53926

WebMD Health

This information is not intended to replace the advice of a doctor

Rev Med Liege. 2002 Sep;57(9):575-81.
[Smoking, insulin resistance and type 2 diabetes]

[Article in French]

Magis D, Geronooz I, Scheen AJ.

Service de Diabetologie, Nutrition et Maladies metaboliques, Departement de Medecine, Universite de Liege.

Smoking is a major risk factor for cardiovascular disease. It is associated with endothelial dysfunction and lipid disorders similar to those found in the insulin resistance syndrome. Studies have thus tried to demonstrate a relationship between smoking and insulin resistance, and between smoking and type 2 diabetes mellitus. Even if their results may sometimes differ, smoking does seem to be associated with an impaired insulin sensitivity that is proportional to tobacco consumption. Nicotine replacement therapies seem also to generate a certain, though lower, degree of insulin resistance. If there is no major weight gain after smoking cessation, the latter is accompanied by a progressive return to normal insulin sensitivity. Several large epidemiological studies recently demonstrated that smoking could increase the risk of type 2 diabetes mellitus, with a relative risk between 1.5 and 3.0. Finally, among type 2 diabetic patients, smoking has a harmful effect on metabolic control and long-term complications of the disease, at least partially by increasing the components of the insulin resistance syndrome. All these observations represent further argument to promote smoking cessation in the general population, and more particularly in individuals at risk to develop type 2 diabetes, as well as in the diabetic population.

PMID: 12440345 [PubMed - indexed for MEDLINE]

factsheet no:23

Smoking and diabetes

Action on Smoking and Health �?November 2002

What is diabetes?

Diabetes occurs when the glucose level in the blood is too high because the body cannot use it properly. Glucose is a sugar that the body makes mainly from the carbohydrates in food. Glucose comes from the digestion of starchy foods such as bread, potatoes, chapatis, from sugar and other sweet foods and from the liver which makes glucose Glucose levels are controlled by the hormone insulin which is made and stored in the pancreas. Insulin helps glucose to enter the cells where it is used as fuel by the body and consequently the amount of glucose left in the bloodstream goes down.

Types of Diabetes

There are two types of diabetes: People with Type 1 diabetes (insulin-dependent) do not produce any insulin. People with Type 2 (non-insulin dependent) diabetes do not produce enough insulin, or the insulin that the body does produce doesn’t work properly.

Type 1 diabetes is the less common form. This type usually develops in children and young adults but can occur at any age. It is thought that Type 1 diabetes occurs when the body’s immune system destroys the cells that produce insulin but it’s not known what causes this to happen.

About 90% of people with diabetes have Type 2 diabetes. This condition tends to develop gradually after the age of 40. However, increasingly, Type 2 diabetes is being diagnosed in younger people, including children. It appears that this is largely due to the fact that individuals have less active lifestyles and an increasing number are overweight. Both genetic and environmental factors contribute to the development of diabetes but the development of Type 2 diabetes is more likely if some or all of the following factors are also present: physical inactivity; being overweight; family history of Type 2 diabetes; previous diabetes in pregnancy. The condition is also more common in people of Asian and African-Caribbean origin. [1]

Prevalence of diabetes

In the UK, there are about 1.4 million people diagnosed with diabetes and a further 1 million are believed to be undiagnosed. It is estimated that there will be up to 3 million people with diabetes by 2010. There are about 33,000 deaths in the UK attributable to diabetes �?about 1 in 7 of all deaths. At least half of these deaths are from cardiovascular disease. [2]

Health consequences

People with diabetes are at greater risk of raised blood pressure, heart disease, stroke, kidney disease, nerve damage and eye complications such as retinothapy (disorders of the retina). [3]

Links between smoking and diabetes

There is a growing body of evidence to suggest that smoking is an independent risk factor for diabetes and that among people with diabetes, smoking aggravates the risk of serious disease and premature death.

In the US Nurses�?Health Study, 114,247 women were followed for 8 years and 2,333 cases of type 2 diabetes were confirmed. After controlling for multiple risk factors, the relative risk of diabetes was 1.42 among women who smoked 25 or more cigarettes a day compared with non-smokers, suggesting a moderate association between smoking and the subsequent development of diabetes. [4]

A similar study of 41,810 middle aged men found that those who smoked more than 25 cigarettes daily had a relative risk of diabetes of 1.94 compared with non-smokers. [5]

A prospective study of Japanese men concluded that age of smoking initiation and number of cigarettes smoked were major risk factors for developing diabetes. [6] Similarly, data from the US Cancer Prevention Study 1 found that as smoking increased so the rate of diabetes increased for both men and women. [7]

People with diabetes already have an increased risk of heart disease, which is further elevated if they smoke. Diabetes acts in several ways to damage the heart: high glucose levels affect the walls of the arteries making them more likely to develop fatty deposits which in turn makes it more difficult for the blood to circulate. People with diabetes are more likely to have high blood pressure and high levels of fats such as triglycerides. They are also more likely to have lower levels of the protective HDL cholesterol^.1

Insulin Resistance

Smoking has also been identified as a risk factor for insulin resistance which can lead to diabetes. People with insulin resistance cannot properly use insulin and such people may initially have higher than normal amounts of insulin circulating in their blood, a condition known as hyperinsulinemia.

Several factors, including genetics and obesity, increase a person’s risk of insulin resistance and smoking has also been shown to increase the risk of this condition. It is believed that catecholamines, a type of hormone, are produced in greater quantity in smokers and act as an antagonist to insulin action. 3 A study of 40 patients with Type 2 diabetes found insulin resistance was markedly aggravated among those who smoked. [8]

Smoking, diabetes and premature death

The elevated risk of heart disease among people with diabetes increases the risk of premature death. In one study of women aged 60 to 79 who smoked and developed Type 2 diabetes, an estimated 65 per cent of the cardiovascular disease deaths among the subjects was attributed to the interaction of cigarette smoking and diabetes. [9] The same study suggested that smoking may trigger fatal events in people with diabetes whose circulation has been compromised due to vascular disease, or blood vessels damaged by a combination of smoking and diabetes. A large prospective study of US nurses found that among those with diabetes the relative risks of mortality were 1.31 for past smokers, 1.43 for current smokers of 1-14 cigarettes per day, 1.64 for smokers of 15-34 cigarettes per day, and 2.19 for current smokers of 35 or more cigarettes per day. [10]

The effect of smoking on complications of diabetes

Smoking is associated with multiple complications of diabetes. Nephropathy (kidney disease) has been shown to be common in Type 1 diabetic patients who smoke [11] and smoking increases the risk of albuminuria in both types of diabetes. [12] [13] (Albuminuria refers to the presence of protein in the urine and can indicate signs of kidney disease.) Another small study of 33 people with type 2 diabetes with kidney disease found that smokers�?kidney function declined more rapidly than that of non-smokers, despite drug treatment, suggesting that smoking cessation could slow the progression of kidney disease in people with diabetes who use ACE inhibitors. [14]

The relationship between cigarette smoking and retinothapy (disorders of the retina) is less well defined than that of other microvascular complications of diabetes.[15] However, some studies have found an association between smoking and diabetic retinopathy. [16] 11

Smoking is also a documented risk factor for both the development and progression of various types of neuropathy (damage to the peripheral nervous system). A retrospective case control study of type 1 and type 2 diabetic patients found that current or ex-smokers were significantly more likely to have neuropathy than individuals who never smoked (64.8% vs. 42.8%).[17] A more recent prospective study found that cigarette smoking was associated with a 2-fold increase in risk.[18]

Benefits of smoking cessation

There is overwhelming evidence that stopping smoking reduces the risk of cardiovascular disease, lung disease, cancer and stroke. [19] (See also ASH Fact sheet 11: What happens when you give up smoking.) As diabetes increases the risk for heart disease and stroke, it follows that stopping smoking will reduce the risk of complications from diabetes such as heart disease. Few studies have evaluated smoking cessation treatment specifically for people with diabetes but the limited research available suggests that smokers with diabetes may be less successful in quitting than smokers without diabetes and that intensive strategies should be considered to optimise successful cessation. 15

One possible explanation for the lower quitting rates among people with diabetes is the fact that stopping smoking is associated with weight gain and this is likely to be of concern in people who have diabetes and are already overweight. One US study found that concerns about weight gain among smokers with Type 1 diabetes were particularly prevalent among women, obese smokers, and those in poor metabolic control. [20] Fear of weight gain was cited by 49% of smokers.

A recent British prospective study of 7,735 men aged 40-59 years found that cigarette smoking was associated with a significant increase in risk of diabetes, even after adjustment for age, body mass index, and other potential confounding factors. The benefit of giving up smoking was only apparent after 5 years of smoking cessation and risk reverted to that of never-smokers only after 20 years. Men who gave up smoking during the first 5 years of follow-up showed significant weight gain and subsequently higher risk of diabetes than continuing smokers. However, the authors concluded that in the long term, the benefits of giving up smoking outweigh the adverse effects of early weight gain. [21]

Stopping smoking also reduces the risk of premature death. The US Nurses�?Study found that among women with Type 2 diabetes who had stopped smoking for 10 or more years had a mortality relative risk of 1.11 compared with diabetic women who were never smokers.10

In the light of the growing evidence demonstrating that smoking is an independent risk factor for diabetes and that it is also an aggravating factor for diabetes complications, smoking cessation advice should be a routine component of diabetic care. Concerns about weight gain should be addressed by health care providers whilst emphasising the fact that the health benefits of smoking cessation far outweigh post cessation weight gain, even in people who are focused on weight management.

Online Source: http://www.ash.org.uk/html/factsheets/html/fact23.html

Hi Iris,

I am so very pleased for you that you have quit using nicotine and that you are experiencing an easy quit.

Congratulations on having already lived for more than a week without it.

My Mum is a diabetic and, although she is a never smoker, has had to deal with so many health problems caused by the diabetes.

In April last year, I wrote the following:

"My Mum is a long time diabetic, had a triple bypass about ten years ago, I don't know how many strokes and how many OPs ... I also spent some my last New Year's Eves and Days in ICU because she had to be rushed in and put on to all sorts of machines ... so often I thought it would be the last time I saw her.

I know diabetes is not an addiction ... but sometimes I wonder ... you see, my Mum really only "enjoys" eating cakes knowing full well that it is not doing her any good. But she can always inject more insulin (well, she can but the damage is still being done). She had to be taken into hospital again about a week ago ... her blood sugar levels had spiralled out of control once again. This time, a severe kidney infection has apparently played a major roll in that, she is on the way to getting better again but when I can go and see her next week, it will be yet another hospital visit."

Since then, there have been some more serious incidents. She has not been "sinning" with sweet stuff any longer and it breaks my hear to see her suffering, even more so as I can't just go and see her any time I wish. Even at that time, though, I really knew that diabetes IS NOT an addiction.

The reason I am putting this in here is that I am glad you have your sugar levels under control now.

I haven't done any research but I remember two articles with re to diabetes, which I'll add below.

Iris, you can be so proud of yourself for having quit smoking. This time, you are not "trying", you are doing it.

Just one thing: please, make sure you don't forget what your using past was like, especially as your quit is so easy now. If you should ever relapse (and I don't wish that for you), you " don't know if you have another quit in you".

Ich wünsch Dir einen so richtig schönen (zucker-) und nikotinfreien Tag in Berlin und eine noch bessere nikotinfreie Zukunft!!

Gitte

476 days and a bit

Smoking and Type II Diabetes

and

message #66, taken from Be prepared to hear some confusing information

Sent: 10/11/2005 13:27

I saw a new tactic performed last week on a news show that has been doing a month long series on smoking and quitting. The expert they brought in made a statement that smoking is a disease like diabetes or high blood pressure. Being a disease like these other two obviously meant that it needed to be treated like the other two, by using medications to treat the disease. I found it to be an interesting new tactic in the new spread of misinformation and misconceptions.

Smoking is not a disease like diabetes or hypertension. People with diabetes cannot wake up one day and just decide that they are not going to have diabetes or primary hypertension anymore. Many people do in fact need medications to treat those kind of illnesses or the secondary problems spawned by the conditions.

Smokers on the other hand do have the potential of one day just stopping and for all practical purposes eliminate the risk of all future damage caused by smoking. In America today we have more former smokers than current smokers, and over 90% of those people who have quit did so without the use of any medication. This statement cannot be made about diabetics or people with hypertension--where the majority of people who successfully overcame the disease did so without any medication or professional intervention whatsoever.

Smoking is not a disease like diabetes of hypertension. Smoking is a disease like alcoholism or narcotic addiction is a disease. You just don't see all of the experts in the world who deal with the diseases of addiction coming out and saying that the answer is all of the users of the world need to be put on medications to quit drinking or to get off drugs. Most people know that the way people successfully break free from addiction is to stop delivering the addictive substance. It seems that the professionals in the field of smoking cessation just cannot recognize what people have known for decades now on how to really gain control over diseases of addiction.

While smoking is not a disease like diabetes or hypertension, it does in fact result in many of the same complications as both of these diseases and others. In fact, people who do have these diseases and also smoke are magnifying the risks of a host of complications from their other preexisting condition. Again, while they may not be able to eliminate the risks and complications caused by their other diseases without medication, they can reduce the risks of problems caused from their past smoking and put an end to any future damage that smoking would cause by simply making and sticking to a personal commitment to never take another puff.

Joel

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Joel

For Those Who Smoke Young

What is diabetes?

Smoking, diabetes and premature death