How to manage diabetes: Expert Q&A

How to manage diabetes: Expert Q&A


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. [MUSIC PLAYING] 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. Sure. 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 does. 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– Right. –also important. 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.

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