Functions Of The Liver In Diabetes

By Dr Harold Gunatillake - Health Writer

Though insulin manufactured in the Islet cells of the pancreas, controls and maintains the sugar level in the blood, the liver also participates hand in glove in a crucial role in the carbohydrate homeostasis during fasting, postprandial (after food) situations, and other emergencies. There are physical, biochemical and metabolic adjustments occurring in the liver in the process.

When you eat your meal, the complex carbs are broken down by the gut enzymes and amylase from the pancreas, into monosaccharides or simple carbs. Simple carbs are like quick burning fuels. Complex carbs break down much slower, and a better choice as the body takes longer time to digest and absorb an essential requirement in diabetes.

The portal veins carry the glucose in the venous blood stream to the liver primarily before being distributed to supply organs that require a glucose energy source. The liver uses glucose as fuel, and the excess stored as glycogen. The liver also has the ability of synthesizing glycogen from non-carbohydrate nutrients such as fats and proteins. It prevents a low glucose level (hypoglycaemia) in the blood stream, and in such an event through gluconeogenesis, maintains the normal sugar level by pumping in glucose into the blood stream. This process occurs by harvesting amino acids and fat byproducts. The liver needs to be kept healthy for this neo-glucogenesis (new glucose manufacture), and when the liver becomes unhealthy may result in hypoglycaemic events, and even produce shock in a starvation situation.

Loss of insulin or insulin resistance influences the liver and leads to breakdown of glycogen into sugar (glycogenolysis), and increases glucose production when required.

Liver stores glucose as glycogen as a food reservoir and also manufactures glucose when it's needed. The process of converting stored glycogen into glucose when needed is referred to as glycogenolysis. You can now understand how one could get lost in the bush and survive for weeks, provided there is adequate intake of water, as the liver takes over the function of providing sugar to the blood stream through neo-glucogenesis and glycogenolysis.

Ketones

When the glycogen reserves get less due to lack of food intake, the liver starts to conserve the sugar supplies to provide energy to essential organs, like the brain, red blood cells and the kidneys. In this emergency situation to provide energy, the liver produces alternative fuels called ketones. The liver forms these ketones from fats stored in fat cells. This process is called ketogenesis. Low level of insulin manufactured in the pancreas triggers the liver to form ketone bodies. These ketones are used by the muscles as fuel, thus conserving the sugar. This would have been the mechanism that helped the 101-year-old man buried for over 6 days in the earthquake in Nepal, to survive.

Fasting blood sugar level

To diagnose diabetes your doctor will request a fasting blood sugar, in addition to other diagnostic tests. Once you are diagnosed there is no purpose in checking the morning fasting blood sugar reading any further. In situations where the fasting blood sugar is high, you would be very worried that your blood sugar is not controlled overnight.

You need not worry about this situation, so long as the post prandial (2 hours after eating) test and random checking tests are within the normal range- i.e. ranges between 7.0 to 9.0 m.mol/dl. The reason why the morning fasting level could be high is due to excessive gluconeogenesis in the liver overnight.

Fatty Liver

The liver must be kept in trim condition in diabetic situations for wellbeing and avoid complications. One must be careful in drinking alcohol in excess. Just a drink a day, the liver enzymes can handle to detoxify. Drinking excessive alcohol causes liver cell damage and fibrosis (cirrhosis)

Diabetics do get fatty livers unless the sugar levels are well controlled. Fatty liver has no symptoms in the early stages other than detecting the condition on a blood test. Fatty liver increases your risk of inflammation or scarring (cirrhosis). Fatty liver may cause diabetes type 2, and having the latter disease not well controlled may worsen the fatty liver disease. To avoid fatty liver, control your blood sugar levels daily, lose weight and maintain a healthy weight. Your blood pressure must be maintained with in the normal range. Keep you lipids (LDL cholesterol and triglycerides) within recommended limits and take just a drink or two of alcoholic drinks daily, not more.

Cirrhosis of the liver and diabetes

There is an increased incidence of cirrhosis (hardening) of the liver secondary to diabetes type 2. It is also observed that the majority of cases having liver cirrhosis have glucose intolerance. Obesity seems to be a notable factor in these cases.

Increased Triglycerides in the blood stream

Fat is stored in fat cells as triglycerides. These triglycerides are transported to the liver through the blood stream. If the triglyceride level is high on a blood test, it also means that too much of triglycerides are transported to the liver to increase hepatic fat synthesis. The most clinical presentation of such a fatty liver is enlargement (hepatomegaly). Excessive accumulation of fat in the liver is seen in alcoholic liver disease, obesity and malnutrition causing diseases. Liver enlargement is common among diabetics due to fat accumulation.

CT scan and ultrasound are sensitive tests to detect hepatic fat accumulation in fatty liver. This explains how one could get a fatty liver. As said before fatty livers interfere in diabetes and sugar control may be affected.

Liver cancer link to diabetes

Evidence is emerging that diabetes is associated with liver cancer. According to the American Diabetes Association, it is unclear whether such association is direct due to hyperglycaemia (increased blood sugar) or due to insulin resistance.
Liver disease affects the glucose control, and it is emphasised that the liver should be kept in prime condition without disease or accumulation of fats, to assist the pancreas in maintaining a healthy blood sugar level,

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