At The Forefront Live: ABC's of Diabetes
March 19, 2019
Coming up on At the Forefront Live, living with diabetes. Now, according to the Centers for Disease Control, more than 30 million Americans have diabetes. That's more than 9% of the population. It's a tough disease that can be devastating if not properly treated. Now, how do you know if you have diabetes, and what should you do to protect yourself? Today, we have an endocrinologist and a dietitian on the program to answer your questions, coming up now on At the Forefront Live.
Hello and welcome to At the Forefront Live. I want to remind everyone that today's program is not designed to take the place of a visit with your physician. And joining us today is Dr. Farah Hasan and Kim Kramer. Thanks for being on the program. We appreciate you both being here.
Thank you for having me.
Thanks for having us.
Let's jump right in. And I, again, want to remind people, start typing if you have questions for our two experts today. We're going to start off with you, Dr. Hasan, and ask, what is an endocrinologist? Because that is what you are.
An endocrinologist is a specialist in hormones and metabolism. We treat disorders such as thyroid disease, parathyroid disease, and diabetes, what we're talking about today.
Great. And how do you get diabetes? I think that's probably the central question most of the people watching will want to know.
So you can get diabetes in a variety of ways. The two main types of diabetes are type 1 diabetes and type 2 diabetes. So type 1 diabetes is an autoimmune condition where the immune system attacks the pancreas, and type 2 diabetes is a condition in which there is insulin resistance and also a component of where the pancreas does not make enough insulin. So type 2 diabetes tends to develop more in adults and older individuals, and type 1 diabetes we classically think of as occurring more in young adults and children.
And Kim, does eating a lot of sugar have anything to do with the cause of diabetes?
Yes, definitely if individuals are having too much sugar in their diet-- a lot of times, it's through sugar-sweetened beverages-- then that's something that-- we definitely see that, where if they cut that down, that their diabetes can actually improve.
So when we talk about sugar-sweetened beverages, this is one that I'm curious about. I think a lot of folks drink the diet beverages that have the artificial sweeteners. And there's a lot of debate on that. And we were laughing a little bit about looking at the internet before the show started. And sometimes, you get good information, and sometimes you don't. And there's a lot of talk about the dangers of artificial sweeteners. Are they actually dangerous?
So artificial sweeteners are considered safe in moderation. It's something that we advise people to use, or if they're having any kind of-- I'm sorry.
So yeah, artificial sweeteners as far as weight loss.
Yeah, so for weight loss, it's perfect. And then, for diabetes control, it's also perfect. So that's definitely something I would recommend. I wouldn't recommend sugar alcohols. That's a little bit different. That can cause some GI issues as well.
Interesting. So what's the difference between type 1 and type 2 diabetes? You talked a little bit about the age ranges and how that impacts, but can you explain to us more the differences between the two?
Sure, so type 1 diabetes tends to occur in children, used to be called juvenile diabetes. It also can occur in young adults. But we also see it in middle-aged and even older individuals. It is an autoimmune condition. So it's where the immune system attacks the pancreas and causes it not to be able to function. Type 2 diabetes is a-- it's what we usually see in older individuals, although more recently we're seeing it in teenagers and younger individuals who are obese or overweight. There is an increasing prevalence at a younger population, unfortunately.
But it's typically what we used to call adult-onset diabetes. So type 2 diabetes starts off mostly with an insulin-resistance picture, where the pancreas is still making insulin but the body isn't responding to the insulin well. And then, over time, the pancreas starts to make less and less insulin. And that's why you need an escalation of medications.
So this could be either for you, Kim, or you, Dr. Hasan. I think as we've noticed changes, particularly in dietary habits of Americans, it seems like we're getting larger as a society. And there are a lot of health issues that are caused by that, and diabetes is certainly one of them. Have we seen increases in diabetic diagnosis, and what can we do as a society to maybe turn that back a little bit?
Well, maybe I'll take the first part of that question.
So we are seeing an increasing prevalence of type 2 diabetes. And that is going along and paralleling the increasing incidence of obesity and people being of a larger size. It also is going along with less physical activity, and we're seeing that present at younger and younger ages. And there are ways that we can prevent the development of diabetes.
So definitely weight management is one of the big ones, to make sure everyone's within their normal body range. So that is definitely something that I would recommend, and then just lifestyle changes, diet and exercise as well.
And Kim, we've talked about BMI on some of the programs in the past. And I think people look at that, and it's a scary number to them, because they don't really maybe understand what that is and how important that is. But if you can keep to that range, or at least fairly close to it, you're going to be a lot healthier in the long run.
So definitely trying to stay that healthy BMI-- all it is, really, is a height and a weight. So it doesn't take into consideration body frame as well. So it's not the end all be all, but it is a good guide.
Good reference point. So Dr. Hasan, can you have diabetes and not have any symptoms?
Absolutely. So the tendency to have symptoms occurs when the blood sugars are over 200 and a hemoglobin A1c range of maybe 8% and higher. And when you have blood sugars that are under that, you may not have any symptoms. And the common symptoms are increased thirst, increased urination, blurry vision, maybe some loss of weight. And you have to have pretty high blood sugars to have those symptoms. So you can have lower blood sugars that would give you the diagnosis of diabetes and be completely asymptomatic. But those high sugars, even though you're not having symptoms from them, still put you at risk for complications from diabetes.
And if you are diagnosed, and you're to the point where the sugar level goes up, what's the first thing that you would tell a patient to do?
Well, the first thing to do is to see your physician and ask your physician what would be the appropriate management. So management includes diet, exercise, medications if appropriate, and checking your blood sugars. So depending on the degree of the elevation in blood sugars, you'll develop a management plan with your physician. And diabetes education and seeing a dietitian are important components of that plan.
So we do have a viewer question. And that is, can you discuss exactly what type 1.5 diabetes is, which I'm not familiar with, and how it differs from the others and best way to control it?
So type 1 and 1/2 diabetes is what we refer to as a person with type 1 diabetes who also has a component of insulin resistance. So these people might have autoimmune diabetes, where the pancreas is not making enough insulin, but they may have a genetic predisposition to type 2 diabetes or be of an ethnic minority or of an ethnicity that has an increase in insulin resistance. So you have a little bit of both type 1 and type 2 diabetes in someone who has type 1 and 1/2 diabetes.
And we had the opportunity to meet one of your patients. And this guy, Maurice, is just a fantastic person, very nice man. And it's interesting to hear his story, because you've been working with him now for several years. And he was recounting some of the treatment and how things went. And the key to this is people can have diabetes and really live a great life. And Maurice is one of those patients who followed the plan, and now he's feeling really good.
When I started, horrible shape, horrible state of mind, pretty much ready to just throw in the towel and say, well, OK, it's all downhill from here. Today, no, [INAUDIBLE], recently retired, living life on my terms, doing all that I want to do when I want to do it, however much I want to do, and really enjoying every day.
Well, he looks great.
He must be doing quite well. And he seems like he's enjoying life, and that's obviously what the whole point is. Another question from a viewer-- this one is, when I found out I had diabetes just 15 years ago, I lost 20 pounds, diet and exercise, was taken off-- I think this should be meds-- three months later. And just two years ago, I had to start meds again because A1c was at 7. Why doesn't diet and exercise work now?
So this individual likely has type 2 diabetes. And diabetes tends to be a progressive disease. So initially, when you're diagnosed with diabetes, the setting and the pathophysiology of the disease process began probably about 10 years prior to the diagnosis of diabetes. So initially, it starts with insulin resistance. Your pancreas is able to compensate and make enough insulin to keep blood sugars normal. And then you get diagnosed with diabetes, and we may give you one medication, such as metformin, to improve insulin resistance, and sugars may stay normal for a while. But in the majority of cases, type 2 diabetes tends to be progressive, and you need an escalation in medications and therapies over time.
Interesting. Another viewer question-- this one's very interesting. How does stress affect type 2 diabetics, specifically PTSD?
Well, I don't think you can separate the mind from the body. Everything is connected, and I think we're only realizing now all of the connections. And there's a lot of research to be done in the future to determine all of the connections. Stress increases stress hormone levels such as cortisol, and psychological stress also increases cortisol. And one of the effects of cortisol is increasing blood sugars. So stress can increase blood sugars, not just emotional stress but any physical, physiologic stress, such as if you have the flu or if you have an infection. That can also increase blood sugars.
And Kim, to piggyback with that question, let's talk about lifestyle changes, because lifestyle changes can mean a lot of different things. Diet obviously is critical to this, but just lifestyle changes in general, maybe, to take advantage of a healthier diet and maybe de-stress a little bit. How important is that, in your mind?
Definitely. So I would say that a carbohydrate-controlled diet is going to be one of the main ways to try to control it. It depends on the amount of carbohydrates that each person should have, depending on their height, weight, gender, and activity level. So that would be a first step for people trying to change their diet.
So when people come in and they see you, you'll put them on a plan. You look at the whole person, again, height, weight, body mass, all that kind of thing, and what they're going through. And then you work with them to develop better habits. And sometimes, just even the dietary and exercise changes can have a pretty big impact, as one of our other viewers mentioned a few minutes ago.
Yes, so even small changes can make a big difference, whether it be, as I mentioned before, trying to decrease the amount of sugar-sweetened beverages, trying to increase fiber foods. It's just the little things.
And Dr. Hasan, I think this is one of those diseases as well where sometimes people are diagnosed, or their diagnosis maybe is even pre-diabetic, and they decide, oh, I'm OK. I can soldier through this. And that's not a good idea. I mean, diabetes can be very dangerous.
Diabetes can be very dangerous. And especially, I think, at the pre-diabetes and early-diagnosis level, that is an important time to make the changes, because you can preserve your pancreatic function, you can prevent yourself from progressing and needing additional medications, needing insulin, and you can prolong your healthy life. So starting early, making those interventions early is extremely important.
And this isn't always easy. Maurice is a great example. He talked to us a little bit about this. He had many struggles along the way, but he stuck with the program, and he made progress.
After starting off slowly with moving and really getting the body moving, and the frustration because the weight does not go down-- you constantly see it going up-- you get frustrated, because you're saying, why am I going through all of this pain when I'm not seeing any results? You start faulting everybody but you. And suddenly, you have that one day where everything turns around, where it starts going in the right direction a little bit, but it's something. And that was the key, is the fact that I saw triglycerides going to a point where they could not be measured to being the high end of the spectrum, but at least it was measurable. And to me, that was an achievement. Now, we can do something about them being high.
Well, he has a great attitude. That's for sure.
He does. He does.
And Kim, when you're working with people like that, particularly on the dietary changes, I imagine it probably is a little bit difficult at first, because anybody who has tried to make changes in their eating habits-- it's hard. And you want that weight to come off, and you want to feel better immediately, but it takes a while. And Maurice is a perfect example of someone who stuck with it and it worked for him.
Yes, usually you just start off making a few changes, because if you go too many changes at once, it could be overwhelming for the patients. So just starting out with a few changes and then going from there, and then they have great results, like Maurice did.
That's great. Another message, or a question-- it's more of a message from a patient. And Kim, this is somebody you know, apparently. It says, tell Kim I ate Cheerios with blueberries for breakfast. Diet change is huge. Kim is awesome at keeping you on track. So that's nice of them.
Well, I don't know who that is, but I'm very proud of you.
Another question from a viewer-- how does periodontitis relate to diabetics? I'm not sure if I'm reading that correctly. Hopefully, I did.
Well, dental issues definitely are impacted by diabetes. So people with diabetes do have a higher incidence of periodontal disease and gum disease. And we do recommend patients with diabetes see a dentist regularly, as the general population should as well.
And that leads to my next question. So foot care is very important for people who are diabetic. Talk to us a little bit about that. What do people need to know? And also, eye care is important as well.
Right, so the leading cause of amputations in the United States is diabetic neuropathy. So it's important for patients with diabetes to take good care of their feet-- nail hygiene, checking the bottoms of their feet to see if there's any ulcers or sores, any blisters or breakage in the skin. With diabetic neuropathy, patients with diabetes lose the feeling in their feet, which can cause to breakdown of the skin that's not felt. So if people are not checking their feet regularly, these can go longer than they should and result in deep infections and infections of the bone that can eventually lead to amputation. So it's important that patients with diabetes pay attention to their feet and check their feet daily.
And again, seeing an optometrist, ophthalmologist--
Mhm. So patients with diabetes are also at risk for diabetic retinopathy, so that's changes in the back of the eye, to the retina. These changes don't necessarily result in a change in vision, and so it's important to go for routine dilated eye exams so the back of the eye can be checked for any early evidence of changes in the retina from diabetes. And then that can lead to interventions to preserve the sight.
Kim, I think this is another one for you, a viewer question-- 60-year-old female, 5 feet 4 inches tall, wants to know what's a good weight. She is diabetic. And again, that's probably a tough question to answer here.
Yeah, that is a tough question to answer. So it just depends on the person, as far as body frame as well. So someone who's 5 foot 4-- ideal body weight is 120 pounds, but that's not going to be practical for a lot of people. So that would just be something that you'd need to talk to your provider or your dietitian about and just see what they would think a healthy weight would be as well.
Yeah, and because it does matter. It makes a big difference person to person. People have different frames and that sort of thing. So that can have a big difference. Another viewer from a question-- Doctor, this one's for you. How often are diabetic meds changed?
So that is really dependent on the individual. So it depends on what your blood sugars are doing, what your doctors think, what your hemoglobin A1C is. So it's really specific to the individual and a difficult question to generalize.
And there probably have been a lot of advances in medication, too, over the years for folks who are diabetic, I would imagine, as well.
Oh, and especially in the last decade, there's been an explosion in new medications. And what's appropriate for different patients is different. Depending on whether there's a history of heart disease or kidney disease, we can really tailor therapy to the individual. So there is an explosion of new medications that have occurred.
That's great. So Kim, why is having good blood sugars so important if you do have diabetes? And can you talk to us a little bit more about specifically what is meant by good blood sugars?
Sure, so good blood sugars-- fasting goal, which fasting would be first in the morning before they eat or drink anything-- that'd be 80 to 130 is the goal there. And then two hours after meals would be less than 180. And that's just a general guideline but can be individualized for each patient. It's important to have controlled blood sugars because that can reduce the risk of complications that Dr. Hasan was talking about earlier.
So that would be the main thing, is to try to keep those blood sugars under control, and then keeping that hemoglobin A1c, as Dr. Hasan had mentioned-- and what that exactly is-- it's a three-month average of blood sugars, how much sugar is stuck to the red blood cells. And so, really, anything under 7 for a diabetic is considered under control.
And Doctor, how often should people check their blood sugar? Does that vary from patient to patient as well?
It does. For some of our really well-controlled type 2 diabetes patients who are on minimal or no medications, we might recommend that they don't have to check their blood sugars. For those individuals who are on insulin, we might ask that they check their blood sugars three to four times a day. So it really depends on the individual.
Great. Another question from a viewer-- what's an ideal breakfast for a diabetic?
Well, it does depend on--
Cheerios and blueberries.
Yeah, right. Cheerios and blueberries I think would be amazing. That would be great. We don't want a lot of cereals with a lot of sugar in them, also, something like eggs with some whole-wheat toast, anything with some high fiber in it. Oatmeal would also be a great breakfast as well. But we really want to watch for portion sizes. And that's the number one thing. We don't want to have too much of the cereal, too much of the oatmeal. Too much of anything isn't going to be a good thing.
So Doctor, please explain-- and this is chromium-- is it picolinate, what it is? And is it effective to use?
So chromium-- there are variable studies. Some studies show it might be helpful. Some studies show that there is no benefit. There is no definitive evidence either way. It's a mineral that you can get in supplement form. There's no good evidence either way.
And that's probably a challenging one for you as a physician. And I know in other programs we've done with some of the other experts, there are a lot of people that will get online and do research, which totally-- you understand that. The information isn't always the best on the internet, though. So listen to your doctor, listen to your dietitian, because they're the experts, and they can really help you. I'm not saying that doesn't work, but buyer beware when you get on the internet.
So how many carbs per meal is ideal for diabetics? I think we're sensing a thread here with our questions. It may be the same person. I don't know.
So as far as carbohydrates go, it is going to be individualized based on the person, anywhere from 30 grams per meal to 90 grams per meal, depending on that person. So it's hard to say. But we do want to spread those carbs out evenly throughout the day, and that's what's important. We want to make sure that they're getting the same amount of carbs for breakfast, lunch, and dinner. Some people will look at it and say, oh, I can have 150 grams of carbs per day. Perfect. I'm going to skip breakfast, I'm going to skip lunch, and I'm going to have a really big pasta meal for dinner. And it doesn't work that way, because that can actually make the blood sugars go up in the evening hours.
Interesting. So Doctor, is diabetes reversible? Once you're diagnosed, is there any hope of going back, or not?
So I don't know if I like the term reversible. I think it's more appropriate to say that it's diet and lifestyle controlled, because if an individual has lost weight and is exercising and minimizing their carbohydrate intake, and their blood sugars are good, it's because of their lifestyle interventions. So they're managing it with lifestyle. So if they stop doing that, and the weight came back, and they went back to poor eating habits, the blood sugars would go up again. So I don't know if I would say it's reversible. I feel more comfortable saying that it's lifestyle managed.
That's a great answer. And a great example of that is Maurice. He's doing well and monitors himself using technology. And he's back to living a very full life.
Diet, exercise, the meds-- all of those have changed over the years and even over the months to where I've gone from seeing her every other month to now being on a rotation, much like my dentist. I get to see her twice a year now, and that's because she has me now on an electronic leash. I can download my blood sugars. She knows where my A1c is. She knows that you're following the exercise program, you're taking your meds like you should. So all we have to do now is play the maintenance program and keep a good thing going.
What a fantastic story he is, because he really shows that it can work if you follow the directions that you all give and do what you need to do. You can really turn things around. And he's a fantastic example.
Yeah, he's been very motivated over the years, yeah. I think what he's referring to there is the recent technology where you can wear a FreeStyle continuous glucose monitor, and he can scan the device any time of the day and see what his blood sugars are. So that's made a huge difference to him.
Yeah, that's fantastic. More questions from our viewers, and these are very interesting ones. A new one-- is cinnamon good in lowering your sugar?
There has been some research out there. There's not a lot of research about the cinnamon. So right now, we're not really recommending that people take cinnamon on a regular basis to lower their blood sugars. As more research evolves, who knows? But that's where we're at right now.
Well, see, when I think of cinnamon, I think of it being on things. And usually, they would be sweet things. So I don't know that that would be a positive.
Well, and you'd have to have a lot of it to get those effects. So some people will take it in pill form as well, but not anything that we're recommending right now.
Another question from a viewer-- I panic when my blood sugar is 200, and I won't eat because I don't want it to increase, but I will be hungry. What do you suggest? Either one of you can jump on that one.
Well, I think it's important to know that not all of the cause of an elevated blood sugar is from the food that's being eaten. So our sugar that's measured in the blood is from two sources. One is from the food that we eat. The other is the sugar that our bodies are able to make. And the main organs in our bodies that do that is our liver and our kidneys. So even if you're not eating, if your liver and kidney are not balanced out with insulin in terms of how much sugar they're making, the blood sugar can continue to rise. So I think that's an important thing to think about. But I'll leave Kim to answer the question about not eating.
I definitely recommend that patients eat even if their blood sugar is high. And if that's something that's going on on a regular basis, then they can talk to the endocrinologist or their provider about it and see if they maybe need a medication change at that point.
Interesting. Another viewer question, very interesting question here-- is it common for type 2 diabetics to fluctuate in weight during the first few months or years after being diagnosed? I hit a wall when I had a tragedy unfold in my personal life-- this gets back, I think, to the stress issue as well-- felt like the added stress has my blood sugar so high even when sticking to my diet plan. What are your thoughts on that?
So weight is very multifactorial, what a person's weight may be. So initially, when a person is diagnosed with diabetes or type 2 diabetes, and their blood sugars are over 200, people often lose weight because they're losing a lot of the sugar in their urine. We call that glucosuria. So there can be initial weight loss. And as medications are given to a patient with the new diagnosis of diabetes, there may be some initial weight gain. So certainly, in the initial few months of diagnosis and treatment, there may be some fluctuations in weight.
Great. And again, more view questions-- we'll eventually have to cut this off, but you can continue to ask questions online, and we'll try to answer those after the program as well. We can forward those to you all as well. But I do want to get to a couple more of these. This one is-- wow-- why does my blood sugar spike to 400 overnight? And they say, I have the pump. Is that something they need to see their physician about?
So an insulin pump is a device that provides insulin continuously, subcutaneously. They're set up with basal rates and bolus settings so that you can take additional insulin when you eat, depending on your carbohydrate intake. If the blood sugars are rising overnight, it sounds like the overnight basal rate needs to be adjusted. And usually, sugars rise overnight-- from what I was talking about earlier, that there is sugar production or a gluconeogenesis from the liver and the kidneys that provide sugar during times of fasting. So it's likely that there isn't enough insulin overnight to balance out that sugar production.
OK, we're about out of time, but I do have two more questions and I want to get to, because I'm trying to do as many of these as possible for people who have stuck through the program. We really do appreciate all the questions. They've been fantastic so far. How often should we test liver and kidney? I'm not exactly sure what they reference there, but maybe you have some thoughts.
We do measure those annually, at least. If there's any other concerns, then I would discuss it with your doctor to see if it needs to be checked more often.
OK, and one last one-- either one of you can take this one. They want to know about homeopathic remedies that can assist in lowering blood sugar levels. Again, I think we like to stick with science, but if you have any thoughts.
There's nothing that's been proven or is in the guidelines at this time. There are nothing that is in large studies that have been shown to be routinely recommended.
Perfect. Always talk to your doctor. That's what we recommend. You guys were great. That was fantastic, and lots of good questions and great answers. We really appreciate it. That's all the time we have for At the Forefront Live today. Thanks for all of those fantastic questions. Be sure you check out our website at uchicagomedicine.org or call 800-824-0200 if you need an appointment.
I also want to encourage you to join us for our next At the Forefront Live. That's coming up March 27 at 3:00 PM, where we will discuss IBD and colorectal cancer. We'll also talk about the original work that UChicago Medicine has done on prevention and risks in this population. Now, make sure you keep up with our Facebook page for more information about UChicago Medicine, including health tips and schedules for future At the Forefront Lives. Thanks again for watching, and I hope you all have a wonderful week.
UChicago Medicine endocrinologist Farah Hasan, MD, FRCP, FACE, FACP, and registered dietitian Kim Kramer answered questions about managing diabetes, the differences between type 1 and type 2 diabetes, how to control diabetes and more in this episode of At the Forefront Live.
What's the difference between type 1 and type 2 diabetes?Type 1 diabetes is an autoimmune condition where the immune system attacks the pancreas, and type 2 diabetes is a condition in which there is insulin resistance in the body and the pancreas does not make enough insulin. Type 2 diabetes tends to develop more in adults and older individuals, and type 1 diabetes we classically think of as occurring more in young adults and children.
Can you have diabetes and not have any symptoms?
Absolutely. People tend to have symptoms when blood sugars are over 200 and a hemoglobin A1c range of maybe 8% and higher. When you have blood sugars that are under that, you may not have any symptoms. Common symptoms are increased thirst, increased urination, blurry vision, maybe some loss of weight, but you have to have pretty high blood sugars to have those symptoms. So you can have lower blood sugars that would give you the diagnosis of diabetes and be completely asymptomatic. But those high sugars, even though you're not having symptoms from them, still put you at risk for complications from diabetes.
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