As we all know achieving good blood glucose control in people with type 1 and type 2 diabetes reduces complications. People whose blood glucose control is not good develop complications like heart attack, stroke, blindness, kidney problems, amputations and many more. It is therefore important to get blood glucose control within the target range. Most importantly, life expectancy is reduced on average by 20 years in people with type 1 diabetes and up to 10 years in people with type 2 diabetes based on a department of health paper (National service framework for diabetes: standards) published in 2001.

HbA1c or glycosylated haemoglobin is a measure of blood glucose levels. Ideally HbA1c should be less than 53mmol/mol. However, a significant number of people have poor blood glucose control. We know that people with diabetes, who have poor blood glucose control had complications with corona virus infection (COVID-19). According to one study, risk was higher in those with an HbA1c more than 58mmol/mol and mortality/morbidity increased as HbA1c levels increased.

What are the current treatment options for diabetes?

In people with diabetes, in addition to lowering blood glucose, it is important to get cholesterol and blood pressure controlled. There are several treatment options for lowering blood glucose in people with type 2 diabetes, which includes

1. Metformin
2. Sulphonylureas (gliclazide, glimepiride)
3. DPP IV inhibitors (Sitagliptin, linagliptin, vildagliptin, saxagliptin)
4. Glitazones (Pioglitazone or Actos)
5. SGLT 2i (Canagliflozin, Dapagliflozin, Empagliflozin, Ertagliflozin)
6. GLP-1 agonist’s Bydureon, Lyxumia, Trulicity, Victoza, Ozempic)
7. insulins

People with type 1 diabetes require insulin not only to control blood glucose but also for their survival.

What factors are looked into whilst starting any treatment for diabetes?

When your doctor or nurse is planning to start you on a treatment to control blood glucose or change the dose, they look into the following factors:

1. Age
2. Duration of diabetes
3. Body Mass Index (BMI)
4. Risk of hypoglycaemia (very low blood glucose)
5. Presence of kidney failure

Despite keeping the above factors in mind while prescribing medications for diabetes, clearly a significant number of people do not benefit from them and their blood glucose control (glycaemic control) remains sub optimal.

So, why do some people continue to have high blood glucose even though they are on correct medications and are taking it as advised?

All the medications for diabetes mentioned above affect either insulin secretion directly or indirectly (sulphonylureas, GLP-1 analogues, gliptins), overcome insulin resistance (actos, metformin) or gets rid of excess sugar in the urine (SGLT2i like the gliflozins). None of these drugs have an impact on how much sugar is absorbed from the intestines.

In addition, all these drugs do not exactly mimic the action of several hormones in the body.

Why do some people develop complications of diabetes, despite good blood glucose control?

The yardstick for good blood glucose control is HbA1c. Glycosylated haemoglobin or HbA1c indicates the average blood glucose in the body for the last 3-4 months. HbA1c levels, however, do not tell us if there was a fluctuation in blood glucose. Some people can have varying blood glucose levels.  That is blood glucose changes from day to day or even hour to hour. People can have blood glucose varying from 5-20mmol/l despite having the same food and engaging in similar activity.

Wide fluctuation in blood glucose is known to cause damage to the organs in the body, more so the blood vessels. Fluctuation in blood glucose is the reason for complications in some people who have HbA1c around 53 mmol/mol.

What is pancreatic exocrine insufficiency (PEI)?

The pancreas is an important organ situated behind the stomach in the abdomen and it has several important functions. Functions of the pancreas can be divided into endocrine function and exocrine function (digestive).

The pancreas as an endocrine organ which produces several hormones including insulin, glucagon, polypeptide and somatostatin.

As part of the digestive system, the pancreas produces digestives juice, which is secreted through the pancreatic duct into the intestine. Important exocrine enzymes include lipase, protease and amylase. Lipase breaks down fats, protease breaks down protein and amylase breaks down carbohydrates in the food.

Any condition which affect the pancreas can have an effect of the production of exocrine enzymes and lead to exocrine insufficiency. People with pancreatic insufficiency can have the following symptoms:

• Steatorrhoea (type of diarrhoea, where in the stool is greasy, frothy, pale and foul smelling)
• Weight loss
• Blood glucose fluctuation
• Tiredness
• Bloated/pain abdomen
• Loss of muscle mass
• Vitamin A, D, E, K deficiency
• Skin, hair, bone and nail problems

Who can get pancreatic exocrine insufficiency (PEI)?

There are several conditions and diseases which affects the ability of the pancreas to produce certain digestive enzymes necessary for digestion. These include:

• Gastric bypass surgery for weight loss
• Dumping syndrome
• Coeliac disease
• Cystic fibrosis
• Chronic pancreatitis
• Pancreatectomy (removal of the pancreas)
• Pancreatic cancer
• Diabetes
• Autoimmune pancreatitis

In most of these conditions, the pancreas is affected by either inflammation or cancer and is unable to produce sufficient exocrine enzymes. Inflammation of the pancreas or pancreatitis is also seen in people who consume excessive amounts of alcohol and those with gallstones.

How does pancreatic exocrine insufficiency (PEI) lead to poor blood glucose control?

The food we eat has a combination of food groups, which include carbohydrates, fats, proteins, diary and fibre. In order to break down these component food groups, our body needs certain enzymes. Most important are the pancreatic enzymes like lipase, amylase and protease.

When there is insufficiency of these enzymes, food in particular carbohydrates, protein and fat cannot be digested. When food cannot be digested, it moves on to the large intestine and thereafter excreted. This process where in digestion does not take place properly and nutrients are not absorbed is called malabsorption.

Complex carbohydrates in the food we eat cannot be absorbed from the intestines. Carbohydrates in bread, rice, pasta and fruits have to be broken down to simple sugars by amylase. When there is exocrine insufficiency, carbohydrates are not broken down and absorbed and hence blood glucose can be low and occasionally fluctuate.

As soon as we eat, that is when food enters the mouth; huge amount of hormonal and neurological messages are sent. There is a constant talk between the gut and the brain. The pancreas starts getting ready and produces insulin to metabolise the sugar coming from the food. However, when food is not absorbed properly as in pancreatic exocrine insufficiency, the available insulin lowers the glucose so low that it can result in unpleasant affects and hypoglycaemia.

Hypoglycaemia or low blood glucose is a condition, when blood glucose drops below 4mmol/L (72mg/dl). When blood glucose is low, the liver converts the stores (glycogen) it has to glucose and increases blood sugar levels. This causes the fluctuation in blood glucose leading to poor glycaemic control.

Moreover, exocrine pancreatic insufficiency (PEI) also causes fat and protein malabsorption leading to low muscle mass. People with PEI have a low body mass index and low muscle mass. Muscle is the organ which burns calories. Low muscle mass can lead to poor carbohydrate metabolism.

How does Creon help blood glucose control and prevent diabetes related complications?

PEI is diagnosed based on symptoms, blood tests and stool test.

Creon capsules replace the enzymes (amylase, lipase and protease) which are not sufficiently produced by the pancreas when you eat. It is recommended that Creon is taken every time you eat if you have PEI.

Get an appointment with your doctor:

• if you have any of the symptoms mentioned above.
• If you suspect you have pancreatic exocrine insufficiency (PEI)
• If your blood glucose is not well controlled despite taking all the medications for diabetes.

Always consult your doctor before you start any new medications.

To learn more about Creon click here

Dr Chinnadorai Rajeswaran is a consultant Physician specialising in Endocrinology, Diabetes and Obesity. As a private endocrinologist he  has private endocrine, diabetes and weight loss clinics in Harley Street, London, Chennai (India), Claremont Hospital, Sheffield, Nuffield Hospital, Leeds and Simplyweight, Bradford.

He has face to face consultations with people from Barnsley, Rotherham, Chesterfield, Doncaster, Wakefield, Huddersfield, Bradford, Harrogate, Leeds, Sheffield, London and Chennai (India). He also offers video consultations.