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(Announcer)
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association; an Association of Independent Blue Plans committed to better knowledge leading to better, more affordable health care for consumers.
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(Dr. Peter Salgo)
Welcome to "Second Opinion", where each week our healthcare team solves a real medical mystery. When we close this file at about a half an hour from now, you'll not only know the outcome of this week's case, you'll be better able to take charge of your own healthcare. I'm your host, Dr. Peter Salgo. And our story today concerns Bernie. Now, you have already met our special guests, who are joining our cast of regulars, Primary Care Physician, Dr. Lou Papa. And Health reporter, Christine Rogers. Now no one on this team knows the case. So let's get right to work. I want to tell you a little bit about Bernie. Bernie is 58 years old. He is divorced. He has three grown children. He sees his doctor regularly, Lou you would be pleased to know. And his doctor always tries to get him to lose weight and to stop smoking. Now Bernie knows he has high blood pressure. And he is good about going to the doctor to have it checked regularly. At this particular visit, his doctor does a routine panel of blood work and a lipid profile. And it turns out that his triglycerides are 260. What are you going to do?
(Dr. Lou Papa)
Well any time I see elevated triglycerides I am also interested in seeing the HDLs because that ratio of the high triglycerides low HDLs depending what his body mass looks like, his blood pressure being elevated, if he is in kind of a pre-diabetic state, metabolic syndrome, or even diabetes.
(Lou)
I'd be interested in seeing if you have the rest of the lipid profile.
(Peter)
Bernie's fasting blood sugar is 100.
(Lou)
Okay.
(Peter)
His two-hour post perennial, which is two hours after a meal, is 204. Bernie's weight is 216 pounds. He is five foot 10. And he has what he - Bernie calls a beer gut. No doctor would call it that, right? His family history is significant for two - for a brother with type two diabetes. And he has had high blood pressure for a very, very long time. So it looks like your suspicion about diabetes is interesting. What - why do I -
(Lou)
Well it's more than interesting it's confirmed.
(Peter)
How do you confirm?
(Lou)
Okay you can get the fasting blood glucose. And if that is elevated above 125 - 126 or greater you are diabetic.
(Peter)
You have been throwing this word diabetes around. I don't want to go any further, before somebody here nails it down. What the heck is diabetes?
(Dr. Steve Wittlin)
Diabetes technically is an elevated blood glucose.
(Peter)
The sugar in your blood is too high.
(Steve)
That's right.
(Dr. Peter Salgo)
Period, That's it.
(Steve)
That's it. Really one can say that diabetes is, when your blood sugar is high enough that puts you at risk for complications that we associate with diabetes.
(Peter)
So again, it's a lot of sugar in your blood. But then people have heard about type one and type two diabetes. What's the distinction here?
(Steve)
In type one diabetes, the classical form, your body recognizes the beta cells in the pancreas as a germ. It goes and attacks it. It's called an autoimmune disease. And wipes out virtually all the beta cells in the pancreas.
(Peter)
So the beta cells in the pancreas-
(Steve)
They are the ones that make insulin.
(Peter)
And insulin is what keeps your blood sugar at a normal level.
(Steve)
Yes.
(Peter)
So without them your sugar rises.
(Dr. Steve Wittlin)
Right.
(Peter)
Okay.
(Steve)
And that's type one diabetes. And there are odd variant forms. But that's the classic form. Type two diabetes is virtually everybody else.
(Dr. Peter Salgo)
Uh-huh.
(Steve)
Your body makes insulin, but not enough. And most people with type two diabetes are what we call insulin resistant. Their body makes some insulin. But the body is relatively resistant to the insulin that you make. And so it is a combination of those two factors.
(Peter)
So that makes Bernie what, type two diabetic? If he is a type two diabetic, we're going to give him the diagnosis of diabetes. Was that what you wanted to do Lou?
(Lou)
Uh-huh.
(Peter)
So how come he doesn't know? Shouldn't he have felt something? You have got diabetes. What does it feel like?
(Gretchen Becker)
I had very high blood sugars when I was diagnosed. And they were up in the 400s and 500s. I felt fine. I hadn't a clue. Except I finally became thirsty and I was peeing all the time. And that's how I was feeling.
(Peter)
But that's the classical stuff, right?
(Lisa)
Yes. When you ask people if they pee a lot, well everybody thinks they pee a lot [chuckles] because it's inconvenient. So ask people, how many times they get up at night to go to the bathroom. I don't know. It's never been tested as a way of checking for diabetes. But you know, most people sleep the entire night without getting up even once. So when people say oh, I get up once or twice, you know to me that is frequent urination.
(Steve)
Now that we have very good and routine blood tests, we're able to diagnose diabetes at earlier and earlier stages.
(Peter)
The early definition. The reason it is called diabetes and the full name Diabetes Mellitus means sweet urine. Right. That's how it was diagnosed. What is he going to think when Lou or some other doctor in a while coat says Bernie, you've got diabetes. What's going right through his mind?
(Gretchen)
He is going to be in shock. He is not going to hear anything else the doctor says in that whole episode. He's thinking, I am going to go blind. I'm going to lose my arms and legs and I may be impotent. I mean all these things are running through his mind. I mean he is scared.
(Lisa)
And I think he would be thinking that he was going to have to give himself shots for the rest of his life.
(Gretchen)
Yes, exactly.
(Dr. Lou Papa)
The only thing I worry about is that he will say, what's that?
(Terry Davis)
Well his brother has diabetes. So he may be thinking about what's happened to his brother.
(Lou)
Right.
(Terry)
And what's going on with his -
(Dr. Peter Salgo)
But is there a significant gap here in the health literacy of America? I mean the people don't understand diabetes. They hear the word, but they don't really know what that word means.
(Terry)
Sure. And it is - the lower your literacy, the less knowledge you will have about that. But even people with high literacy may have a lot of misinformation and confusion about diabetes.
(Peter)
But you know diabetes is a pretty common disease. Right. How common is it in this country? Is it an epidemic?
(Lou)
It's getting more and more common, that's for sure.
(Terry)
Twenty million people.
(Peter)
Twenty million people. But let me stop you there. Is it more and more common, or if I listen to you correctly, you say we're better at diagnosing it. Did it always exist and we just didn't know it?
(Steve)
No. It's a combination of both. We're better at diagnosing it. We know that somewhere between a third and half of the people in this country with diabetes don't know that they have it.
(Peter)
How many million people is that, do you think?
(Steve)
That's probably somewhere in the order of six to seven million people.
(Peter)
Six to seven million people have a potentially serious disease and don't know it at all.
(Dr. Steve Wittlin)
Right.
(Peter)
Which goes back to your literacy issue, I suspect.
(Terry)
Well in our medicine clinic, 80 percent of the patients are overweight or obese. And so about 80 percent of those have avoidable chronic disease, because they are not exercising. And they are not eating right. And they are obese.
(Christine)
Well some people refer to it now as Diabesity.
(Dr. Peter Salgo)
In terms of the cause of death, just to diabetes alone, where does it rank in America?
(Steve)
It is I believe in the top four.
(Peter)
You mentioned that we're better at diagnosing it. But I am getting a sense, that maybe it is not so easy to diagnose. And it is not quick and dirty. And a lot of people are just under the radar. Is that it? I mean is it just tough to diagnose in the population?
(Steve)
Actually it's pretty easy to diagnose in the population. It's just a matter of looking.
(Peter)
If as you say, diabetes is easy to diagnose, then who is not doing the diagnosis? Are all of us with our MDs attached to our names here guilty of being in a group that is not doing our job?
(Lou)
Sure. I think that's part of it. I think it is also, it is not clear on who you screen.
(Peter)
I want to stop you there. If seven percent of America has diabetes and doesn't know it, a huge percent of America has diabetes and does know it, why don't we - I mean we are talking enormous percentages.
(Lou)
Right.
(Gretchen)
A lot of people don't want to know. A lot of patients don't want - the test is cheap. For a dollar, you can test someone's blood sugar after eating, and get them in the early stages. But a lot of patients don't want to know.
(Christine)
So what's the criteria you use then, if you say people who are at risk, then how would you determine who is coming through your office that you would actually use to test?
(Dr. Lou Papa)
You know, this is what happens in practice all the time. The hard core, you know, if you look at the hard-core evidence, there is nothing that says that you screen the whole population you reduce outcomes. Everybody feels that that's the case, but the data is not there.
(Peter)
Okay. So who is at high risk? In other words, if we are going to say for whatever reason, we can't screen every person in America, you can at least set up a hierarchy of those at high risk that need to be screened right away. So what is this list of people at high risk?
(Steve)
Okay. It includes people who are overweight. People with a family history of diabetes. People who have had gestational diabetes. That is women who have had diabetes during their pregnancy, which is transient and goes away. They have as much as a 30 to 50 percent chance of developing diabetes. And it turns out that if you are not Caucasian, you have an increased risk of having diabetes, per se.
(Peter)
Is age alone something that you would use as a criteria? Lisa?
(Lisa)
Yes. I mean, the older you are, the greater your risk of many things, including diabetes.
(Dr. Peter Salgo)
So I need to get tested. But you don't yet?
(Lisa)
No.
[laughter]
(Peter)
You know again, if you are not going to test everybody, does that put the illness on the patient? I mean should Bernie have gone to his primary care doc and said hello, I'm Bernie, please test me for diabetes.
(Lou)
I think -
(Peter)
And is that fair?
(Lou)
Yes sure. As an educated patient, it is always a plus.
(Peter)
That's what you did, right Gretchen?
(Gretchen)
Yes pretty much.
(Peter)
Tell me about that.
(Gretchen Becker)
They did a urine test. And I'd had a candy bar before I went because I wanted to make sure that I really had some sugar because
[LAUGHTER]
(Gretchen)
So sick of going to the doctor and him telling me everything was normal. So I said okay this time - so I had this candy bar. And it was taking forever for the urine test and she said - And I said what took so long? And she said well the number was so high we thought our machine was broken.
[laughter]
(Peter)
Why don't we just spell this out? What's the big deal with diabetes, Lisa?
(Lisa)
Well it puts you at great risk of the number one killer in America, heart disease. I mean people with diabetes are heart attacks waiting to happen in some ways. You know it puts your kidneys at risk. It puts your eyes at risk. Puts your legs at risk. You know it's a terrible disease if not treated.
(Dr. Peter Salgo)
Can I ask the obviously difficult and impossible question here, why? Why does sugar, an insulin dysfunction lead to eye trouble, nerve trouble, blood vessel trouble, kidney trouble, and eventually to premature death?
(Steve)
When you take sugar and sprinkle it on a protein and heat it up, it affects that protein. The sugar attaches to the protein. And that does funny things. It changes the function of the most important constituents of your body. If you don't have enough insulin, your body starts breaking down protein and turning it into sugar. And so all of those things combined pick on your body. But as one of my friends said in an analogy I found dramatic and I use often, essentially, when you go to a fancy restaurant, you have custard in the kitchen. Someone sprinkles some sugar on it, flame it and you get crème Brule. When you have diabetes, you are cooking sugar with protein, at 98.6 degrees Fahrenheit, your body temperature; your body is making crème Brule out of itself.
(Peter)
I'm not sure I am happy about this. But that is going to stick with me. [laughter] Let's pause for a moment because we have covered a lot of ground here. I want to sum up just very briefly where we have been. I think it is fair to say that diabetes is an epidemic in the United States. People at risk for diabetes need to be screened. The diagnosis needs to be made early. And then of course the question is, who needs to be screened, and is it just everybody, which we didn't really resolve, I don't think. But let me tell you a little bit more about Bernie. He heard the word diabetes. And after shutting down, as you said, he is ready to pay attention. In fact, Bernie said it was a wake up call. That's the word I have here in the chart. He promised he would change his ways. He would start to exercise, eat right, and "kick this diabetes". Does that work? Can you kick diabetes, Lisa?
(Dr. Lisa Sanders)
Absolutely.
(Peter)
You can.
(Lisa)
You can. You can if you are on the road to diabetes. If you have pre-diabetes, there is very good evidence that you can avoid - certainly postpone - possibly avoid altogether ever getting - ever arriving at the diabetes diagnosis. And its diet and exercise. And we say that as if diet and exercise - well naturally. But those are actually very hard. Most people if you gave them a choice would pick a pill.
(Peter)
So if he talks to his doctor, does Bernie. And he says look, I am really motivated. I am going to do diet and exercise doc. Give me a break. I don't want any medicine. I don't want any shots. I want to try diet and exercise. How long are you going to give him to try this, Lou?
(Lou)
I like to give a patient several months, at least. Three to six months allow them to try that. Because it is going to take that long to see that kind of an effect.
(Peter)
So Gretchen, did they let you go? Did you try diet and exercise first?
(Gretchen)
No, actually I went right in pills. Metphormin, which is also called Glucophage. But that's - my blood sugar was so high, to me that was a great motivation. I wouldn't mind dropping dead of a heart attack. But I really didn't want to go blind and be on dialysis.
(Peter)
We're always taught in medical school and in house office and even in practice, that there is such a thing as a diabetic diet.
(Steve)
What we're essentially looking for is a prudent diet that lacks simple sugars.
(Dr. Peter Salgo)
First of all, when somebody is in a doctor's office, and the doctor says okay, I'll let you use diet and exercise. Go and do good work. Does the patient know what that means?
(Terry Davis)
The person has no idea what you are talking about. And you have no idea what the patient is thinking.
(Peter)
Probably the doctor has no idea either. Which is why it's so vague right?
(Terry)
And the deal is, changing how we eat and moving, eating right and moving more is difficult. So a goal would be for patient to figure out what they would do and do small steps.
(Christine)
You're right, your eating habits are so ingrained that changing those is going to be incredibly difficult as I am assuming it will be for our patient.
(Peter)
Well you may assume but I will tell you Bernie did. Would you like to know Lou?
(Lou)
Yeah sure.
(Peter)
Bernie said that he negotiated with his doctor; his doctor gave him six months to come back and improve the situation. So Bernie went away and each time that after six months he comes back to the doctor and he says, I've been on the treadmill, I've been exercising four times a week, I've cut out alcohol, soda and desserts and at the end of six months Bernie was still overweight, he was still smoking, still hypertensive, and still a diabetic. Why?
(Steve)
I think that part of the problem is that to succeed with diet and exercise your expectations need to be quantified. The patients need to meet with a nutritionist and they are going to define exactly what diet means. Because all of us tend to underestimate the number of calories that we consume. If we just wing it we're going to overeat, especially in our society of abundance. Secondly in terms of exercise, I'm on the treadmill, I'm on the treadmill can mean 5 minutes, I'm on the treadmill can be an hour.
(Peter)
What are you going to do now? Here he is, its six months later, he thinks he's done what you have asked him to do and should be better and in fact he's unchanged, now what?
(Lisa)
Now let's not get on Bernie's case, he's worked hard at this but this is a tough disease. So, not everybody can fix it with diet and exercise. I don't think you should make him feel bad that he's not there. I think this is the time to add medicines but you know he's doing the right thing.
(Peter)
Somebody was reading your mind, which might have been a very pleasant moment because they went ahead and put him on medicine. They said they gave him Glucotrol. That what you wanted to do?
(Lisa)
No.
(Dr. Peter Salgo)
Why not?
(Lou)
Are you sure? [laughter]
(Peter)
Wait a minute they misread your mind.
(Lisa)
Yeah, they misread my mind. I mean I think the impulse to go to medicine is absolutely right. Metphormin actually reduces the amount of sugar your body makes. When you have diabetes, not only can your body not handle the sugar you eat, but it gets out of whack. It starts making its own sugar. And that adds to the glucose that's in your system. So what metphormin does is cut down the amount of sugar that your own body makes. And so you don't necessarily - so it doesn't promote weight gain. All the other ones just give you more insulin to help you deal with the glucose that is there. And it makes you gain weight.
(Peter)
The fact of the matter is, Bernie was put on Glucotrol. So let me tell you what happened. Because for six months he's been left on this drug. Comes back to see his doctor. His blood sugar is 282. His HDL is 26. his hemoglobin A1C, his glycosylated hemoglobin, the number you wanted to hear, is 6.8. And his blood pressure is being managed by an ace inhibitor and a diarrhetic. So what do you think is going on here? It doesn't sound like his diabetes is that much better. His sugar is way out of whack.
(Dr. Lisa Sanders)
Well I don't know, his hemoglobin A1C is not bad. 280, you don't know if he just had a candy bar right before he came into the office [chuckles]
(Peter)
He really wants a second drug?
(Lou)
It's a good point though. That's the problem with the random blood sugars is that's just the snap shot in time. The glycosylated hemoglobin gives more of a movie picture of what is happening over time. So those are pretty nice numbers there.
(Peter)
I'll give you more information about Bernie. First of all, his physician was concerned that his glycosylated hemoglobin was still high. And his blood sugar was very high. That for whatever reason he was not getting normalized. But do we have any opinion as to why he wasn't getting normalized by the way?
(Dr. Steve Wittlin)
It was after a meal.
(Peter)
It was after a meal?
(Steve)
No. I am suggesting that he is not controlling his after meal sugars.
(Lisa)
I also think you know, they put him on a drug and they sent him out for six months. That's crazy. Why should patients have bad sugars for six months? I usually put my new diabetics on a regimen where they just check their sugars first thing in the morning. Because if you can't get those under control, your after meals are not going to be controlled. So I call them up after two weeks and say, tell me your sugars for the last week. And then we go from there. I say okay. Do this with your medicine. Because you need to manage it. You can't just magically know what dose is going to be the right dose for a patient. It has to be an act of participation.
(Dr. Peter Salgo)
And there is one thing that Bernie does very well, is he keeps appointments. He does come back to his doctor's office. And he is still smoking. And he has actually gained weight. His glucose is up a little bit compared to his previous office visit. So he gets put on an insulin sensitizer, along with his Glucotrol. What the heck is that, and how do those pills work together?
(Steve)
Good question. By insulin sensitizer, we talked about insulin resistance earlier. It's any drug that reduces insulin resistance. They make your body - mainly your body's muscle, but also to some degree your body's liver more sensitive to insulin.
(Peter)
Is it too dumb to ask, why not just give him insulin?
(Lisa)
Well he has got plenty of insulin. He has enough insulin so that if we had his insulin levels flowing through our bodies, we would all be dead from hypoglycemic shock. The problem is that his need for insulin is astronomical.
(Steve)
Insulin virtually always works. The major reluctance t use insulin is that in the last 10 to 15 years, because of the proliferation of drugs that sensitizes to insulin, there has been a major emphasis on this disease on insulin resistance. And so I think that insulin is an excellent consideration.
(Peter)
So Lisa and Lou are wrong? They are just wrong?
(Steve)
It's a different approach.
[laughter]
(Dr. Lou Papa)
It's the specialist versus the primary care doctor.
(Peter)
He is being very polite. It sounds like he said you guys are wrong. You want to fight back?
(Lou)
You've heard it from the patients themselves. They are terrified of that needle. They are terrified. Even though it doesn't hurt, a sharp object is scary. I mean it just - it's a fact.
(Peter)
Well let me tell you about Bernie. Three months have gone by since he has been on Glucotrol, the insulin sensitizer. He is back. Back in his doctor's office. And this time his physician did a urinalysis and found a trace of protein in his urine. What's going on here?
(Lisa)
It's a logical consequence of having poorly controlled diabetes. One of the results of the crème Brule of his system is that you know it damages the kidneys.
(Lou)
Patients who start spilling protein in the urine have a much higher risk for vascular outcomes at that point. Bad vascular outcomes.
(Peter)
I'll tell you about Bernie. About five years after the diagnosis now. We have jumped a little bit forward in the chart. Things have gotten a little worse for Bernie. He is now diagnosed with peripheral edema. And his doctor says he's got renal failure. Was this predictable?
(Lisa)
Certainly. If you have got good control of your diabetes, you wouldn't expect his kidney disease to progress this quickly over five years.
(Dr. Peter Salgo)
Let's just pause here for just a moment and sort of sum up what we have covered so far. Diabetes turns out to be very, very complicated, now doesn't it? Now it's not just about sugar. The goal of diabetes treatment is to get your blood sugar normal and to keep it there. The solution is not the same for everyone. And I think it's fair to say you do whatever it takes. Whatever medication, diet, exercise to get the blood sugar under control to try to avoid the other complications of diabetes. I'll tell you a little bit more about Bernie.
(Terry)
You know.
(Peter)
Yes.
(Terry)
We have focused just recently on all the severity of the disease, the complications, and all the things that physicians can do medically. And we have moved away from what Bernie and his family, and any support system could do to keep working on his behavior. He is the one that is living with this. And it is not just the doctor that is coming in and adding another medicine every visit.
(Christine Rogers)
That's the tough part of all this. If self-management obviously is so critical for this disease. But having someone - equipping them with the tools to effectively self manage this disease I think is the hard part.
(Steve)
Which I think leads to the notion of a team. And it's why we as healthcare delivery system have been so unsuccessful in treating diabetes is because patients with diabetes need a team. And it requires more healthcare resources than we as a country have dedicated to that.
(Christine)
So what would have made your journey a little easier, do you think?
(Gretchen)
Um, I am not sure. But I would like to put in a word for patient support groups. I think they are very important. I am on an internet support group. And people will - newbies will come and they say I learned more in a week from this than I did from my doctor's office for six months. Because there are people there who have the disease. They know what it's like. They know how hard it is. And so they get real support.
(Peter)
If everybody did like Gretchen. Went on the Web, got integrated into some sort of support group. Talked to the doctors. Got optimal therapy. Stopped smoking, lost weight. Do we then say to all these diabetics, all of your complications don't have to happen? Is that a fair thing to tell them?
(Lou)
No. I don't think that's fair to say about any disease. Anymore than you can say if you wear your seatbelt and you have an airbag in your car and you drive great you won't get in a car accident.
(Peter)
Lisa, what do you say?
(Lisa)
You can't control it. You can't guarantee it. All you can do is try to hedge your bet.
(Peter)
Let's see if we can summarize this. Tight control of diabetes, which is close control of your sugar can significantly delay the onset of complications, sometimes by decades in many, many people. But, there are no guarantees. Is that fair? Everybody agree with that? Because I can take you forward into Bernie's history. It's 10 years now that Bernie has been treated. Bernie's kidneys have failed. He is on a kidney machine. What percent of diabetics end up with renal failure supported with a kidney machine? Do we know the numbers?
(Lou)
I don't know the numbers.
(Dr. Steve Wittlin)
Yeah we do. Unfortunately. It's somewhere between 20-25 percent. It is the leading cause of end-stage renal disease in this country, diabetes.
(Lou)
Is that all comers, type one, type two?
(Steve)
Yeah. Type one is obviously -
(Dr. Lou Papa)
Right. More of them.
(Peter)
Gretchen, how are you doing?
(Gretchen)
I think okay, but who knows? [chuckles]
(Dr. Peter Salgo)
You think okay, but who knows?
(Gretchen Becker)
Yeah.
(Peter)
I mean is your renal function, do you know if your kidney is doing all right?
(Gretchen)
I think we're okay with - yeah.
(Peter)
Well that's terrific. It sounds like you are very aggressive in managing your blood sugar and your diabetes. I'm just wondering if anybody else has anything to say about Bernie. Could something have been done earlier for Bernie? Did we fail Bernie as a system?
(Lou)
This is always frustrating when you are in primary care. You know there are patients that have to get the diabetes under good control. And those that aren't - not - don't get it under good control. And you do wish there was a better network, better coverage for patients and some of those things that Steve was talking about.
(Dr. Lisa Sanders)
It really has to be an ongoing collaborative relationship between the healthcare system, and the patient and his system.
(Peter)
I want to thank all of you. This has been a tremendous discussion. We have come to the end. And before we leave I sort of want to wrap up what we have covered today. We have covered an awful lot of ground. So let's just sum up some key things to remember. First of all, diabetes is an epidemic in the United States. People at risk need to be screened and diagnosed early. The goal of diabetes treatment is to get your blood sugar normal, and to keep it there. The solution is not the same for everyone. You've got to do whatever it takes to control it. Tight control of diabetes can significantly delay the onset of complications, sometimes even by decades. It's very, very important. And of course our final message is always this. Taking charge of your health, means being informed. And having quality communication with your doctor. I'm Dr. Peter Salgo, and I will see you next time for another "Second Opinion".
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[music]
(Announcer)
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