(upbeat music) (upbeat music continues) - Welcome to Forum 360, with its global outlook and local view.

I'm Ardith Keck, your host.

It is necessary to play an active role in safeguarding your health.

Along those lines, one of the most prevalent diseases is diabetes.

It is increasing as our communities grow older.

To learn more about diabetes, a specialist is here to inform us.

With me is Dr. James Salem, specializing in endocrinology, diabetes, and metabolism.

And he's got 29 years of experience.

He's with the Summa Health System in Akron, and he's the chief endocrinologist there and also at Northeastern Ohio University College of Medicine and Pharmacy.

This is your opportunity to protect and improve your health by learning more about diabetes.

After all, it is all around us, with more than 37 million people in the US living with diabetes.

Dr. Salem, what is diabetes?

- Well, diabetes is a disease state whereby we do not handle glucose or sugar properly in our bodies.

Glucose is the fuel for our cells and our bodies, and it belongs in our cells.

And insulin is the hormone that helps usher glucose into our cells.

So when we have diabetes, there is a breakdown whereby glucose gets stuck in the blood but can't get into the cells.

And when it can't get into the cells, A, the cells can starve 'cause they don't have their fuel.

And B, by virtue of getting stuck in the bloodstream, it causes other complications like increased risk of heart disease and kidney failure and eye problems, just to name a few, which will cause problems later on in our lives.

- What are the symptoms?

Suppose I come up with a couple of symptoms, I should go and check those out pretty quick.

- Absolutely.

So, the number one symptoms set can be a loss of weight for no apparent reason.

If a person isn't dieting or doing other things to make them lose weight.

They can urinate more frequently than usual.

The word diabetes comes from a Greek term siphon.

It's sort of like your life is being siphoned away, so you're losing weight and you're urinating frequently.

You may get blurred vision.

Sometimes people will get numbness or burning in their hands or feet, in the extremities, because the nerves are being irritated or damaged by the high blood glucose levels.

So those are the big symptoms to look for.

Although most people who get diabetes don't necessarily have those symptoms because blood glucose levels or blood sugar levels have to get pretty high for a while for us to begin to manifest those symptoms which is why it's important to go to your general medical doctor and get your blood glucose levels checked along with those other health maintenance things, which I'm sure you emphasize, to screen for diabetes or for conditions that lead to diabetes like prediabetes.

- So, how do you diagnose diabetes?

- So, diabetes can be diagnosed either by a blood glucose level.

If a single blood glucose level is high enough, then we call it diabetes.

Or if we have a series of blood glucose levels that are higher than normal.

So, if more than one blood glucose level in a fasting state, eight hours of fasting, is 126 milligrams per deciliter or higher, we diagnose diabetes.

Then there's also a test called a hemoglobin A1c, which we can use to diagnose diabetes and to follow diabetes to see how well we're doing with patients.

And if a hemoglobin A1c on two occasions is 6.5% or higher, then we call that diabetes.

And then there are conditions that lead to diabetes, like pre-diabetes, and we have criteria for those as well.

- Yeah, we have to talk about pre-diabetes.

But how does insulin, which I think is the most prevalent way of treating diabetes, how does it work in our body?

- So, on our cells, where the glucose, the sugar belongs, there are receptors.

And when insulin interacts with those receptors, it sort of opens the door to the cells to allow the glucose to go into the cells and be used as fuel.

So that's how it should work.

- Does diabetes cause damage in our bodies?

- Yes, yes.

It can cause a lot of damage.

There are increased incidences of heart disease, increased incidences of stroke, of blockage of blood vessels peripherally.

So you'll see people with foot ulcers and wounds and things like that.

And the main mechanism by which diabetes causes damage is blockage of blood flow.

That glucose that sort of gets stuck in our blood instead of getting into the cells, by means of biochemical rearrangements, causes blood vessels to sort of block off.

It can cause increased loss of vision.

It's the number one cause of blindness.

It can cause nerve damage, stomach damage, kidney damage.

But the good news is that if we treat it properly, we can decrease the chances of an individual patient getting those disorders a lot, we can really help.

And if the patient and their doctor or their provider work together, it's a whole different era than it used to be.

So we can really prevent those problems.

- Ooh, that's good.

Are there other health concerns for people with diabetes?

- So yes, there are a whole host of things that sort of go along with diabetes.

So, there are two main types of diabetes, type one diabetes and type two diabetes.

Type two diabetes is caused by a lack of sensitivity to insulin.

So the cells, when insulin sort of knocks on the door and asks for the glucose to come in, don't respond as well as they should.

They can respond, but not as well.

We call that insulin resistance.

- Is there an age for type one and type two?

- Yes, there is an age range where we see more of one versus the other.

Traditionally, they said you couldn't get type one diabetes at extremes of age as we get older.

That is not true.

We have found that that is not true.

And we see type two diabetes in younger folks as well.

In some series, we see that even for patients who are diagnosed in the teens, type two diabetes is very prevalent and that's linked to being overweight or being obese.

So, in patients who have this insulin resistance that I was talking about, there are other conditions like high blood pressure that run along with it, or high cholesterol that run along with it, or sleep apnea that run along with it.

So when we take care of diabetes, as part of limiting the risks of all these bad things we don't want to happen and can prevent, we have to think about those other entities and look at a patient's cholesterol, look at a patient's blood pressure.

Screen them for sleep apnea if that's appropriate.

And those things combined to even reduce the incidence of the problems that we mentioned even further.

- So it's really important to get treated.

- Very important.

Very important.

- And pre-diabetes, you mentioned it, it's estimated that one in three people in the US have pre-diabetes.

- Right, and you mentioned the staggering statistic about how many patients in the United States have diabetes.

There are more patients who have pre-diabetes than diabetes.

And pre-diabetes is a condition whereby you are at risk for developing diabetes over time.

And depending on the series on which statistic you read, they're all very similar.

There's probably about a 40% chance of an individual getting diabetes, getting diagnosed with diabetes in the next five years or so if they're diagnosed with pre-diabetes.

But again, same story.

If you're diagnosed with pre-diabetes, you know you have it, you do the right things, you can limit your risk of progression to diabetes by over a half.

So it's quite, you know.

- At one point, I was diagnosed with pre-diabetes and I lost, I think, 30 pounds.

- Good for you.

- And that changed the picture.

- That's great.

- That's what happens.

- Awesome.

God bless you, that's awesome.

Good.

- Does diabetes, when you are diagnosed with it, does it require a lifestyle change?

- Yes, it does.

We've been mainly talking about type two diabetes and pre-diabetes, and those two go together.

So, patients who have type two diabetes or pre-diabetes need to work on their weight, as you mentioned.

They need to increase their activity.

Why?

Because there are studies that tell us that if we do that, it really helps.

There was a landmark study called The Diabetes Prevention Program whereby patients were given proper diet instruction geared towards weight loss, gradual, slow weight loss that stays off.

And they were also given an exercise program whereby they increase their aerobic activity.

And there were three groups of patients in that study.

So, there was a control group and those patients were given the medical knowledge which was available at that time.

So they were given advice, but not as specific advice as the intervention group with the exercise.

And then there was a group that was put on a medication called metformin, which we still use very commonly to treat diabetes.

So, the patients who were in the group were with the exercise and lifestyle modification, as you mentioned, reduce their risk of developing diabetes by over 50%.

Most people thought the drug group would do the best.

The group with the medication reduced their risk but only by about 30%.

I mean, that's great, that's significant.

But that just shows you, as you mentioned, lifestyle modification is huge in the treatment of diabetes and in the prevention of diabetes.

- Welcome to Forum 360.

I'm Ardith Keck and I'm here with Dr. James Salem MD, who is a specialist in endocrinology, diabetes and metabolism.

He's been practicing and he's the chief of endocrinology at Summa Health System and at Northeastern Ohio.

I'm so used to saying NEOMED.

Northeastern Ohio University College of Medicine and pharmacy.

So, is there a way to prevent diabetes?

- Yes, yes.

There is a way to prevent diabetes.

If we can keep our weight at the appropriate level or close to the appropriate level.

If we can be active with as much aerobic activity as we can.

However, there are lots of us who can't do aerobic activity or a high intensity aerobic activity.

The more active we can be, the more we make our body sensitive to insulin.

So, that door that's kind of partially closed, that insulin kind of knocks on to let sugar in, it kind of, by being more active, it makes that more responsive and we can get sugar into the cells where they belong, which is the problem.

So yes, we can prevent diabetes by doing that and we can prevent progression of pre-diabetes to diabetes.

And even for patients who have diabetes, if they do those appropriate things, it makes it much easier to treat and to prevent the problems.

- Is diabetes genetic?

- So, there are genetics of diabetes.

So, we haven't talked a whole lot about type one diabetes.

Type one diabetes is the kind where the cells in the pancreas, the islet cells, beta cells, that make insulin get shut down by an autoimmune attack.

So in other words, we make an antibody to something we don't know what it is and that antibody accidentally attacks these cells, so they gradually lose their ability to make insulin.

There are genetics to type one diabetes.

So if patients have certain genetic outlays of how they respond to antibodies or challenges, then their propensity to make these kinds of antibodies that knock off the beta cells is higher.

In type two diabetes, which is the kind that is governed by insulin resistance, but there is also an insulin production deficit.

That's the more common type.

Yes, there are genetics, there are more complex, but there are definitely genetic predispositions.

You know, we said that being overweight is a risk for diabetes or being obese is a risk for diabetes.

But certainly, not everyone who is overweight or obese gets diabetes, thank God.

So, one individual with the same weight may have a different genetic outlay to begin with with how sensitive they are to insulin in the first place.

And so that kind of governs that.

And then there are less common types of diabetes that we call monogenetic whereby we can trace a certain gene that is inherited that gives a patient diabetes, but those are very uncommon types of diabetes.

- Can it be cured?

- So the short answer is no, the short answer is no.

If you strictly look at what cure means, the answer is no.

But A, as I mentioned, we can treat it very well.

We have an array of tools to treat it.

B, some patients who do the appropriate things lifestyle-wise or even have surgical intervention for weight loss can make it so that they no longer need medication for their diabetes.

That may or may not be permanent because, as I think I mentioned, as we age, our sensitivity to insulin gets worse.

Or if we have type one diabetes and we don't make insulin, no, we're not curing that, and the patient will always need insulin.

And in type two diabetes, if the patient is to the point where their insulin production has shut down, yes, they're gonna need insulin no matter what we do.

However, some of the patients who lose weight and get more active and are on medication can go off their oral medications or even their insulin for indefinite amounts of time if they do the appropriate things.

- So it can't be cured, but it can be reversed.

- That's a great way to put it.

It can't be cured, but it can be reversed.

I would agree with that 100%.

I would add that those patients who are reversed need to monitor with their doctor over time to make sure that their body's chemistry hasn't changed such that they're more insulin resistant than they were before when they first started losing weight just because of time.

As we age, we get less sensitive to insulin.

Or they haven't lost some insulin capacity that they had before, such that they now would be classified as having diabetes and maybe need medication.

Because if that's happening and they don't know it, that's when we start getting the complications.

- Hmm.

You mentioned a couple of other treatments besides insulin.

- [Dr. Salem] Oh, yes.

- But there are others.

- Oh, yes.

When I began to practice 29 years ago, we only had one class of oral glucose lowering agents, so it was that or insulin.

Now we have numerous classes of oral glucose lowering agents that attack diabetes in different ways.

Some of them make the body more sensitive to insulin.

Some of them make it so that we absorb carbohydrate at a slower rate to allow our bodies to catch up.

Some of them boost insulin production capacity.

Some of them make it so that we're able to get rid of excess glucose or sugar in our urine more avidly than we would.

So, some of them make it so that we lose weight to help us become more sensitive to insulin.

Then we even have surgical treatments in patients who have a degree of obesity that is severe enough to be treated by those things.

So, there are numerous treatments now that we didn't have before.

Even in the insulin realm, we have different kind of tailored types of insulin that really can work for a specific purpose.

We have fantastic insulin pumps that we use for appropriate groups of patients.

We have continuous glucose monitors that allow patients to know what their blood sugar is all the time, so they can make adjustments.

And some of those even are paired with insulin pumps so that the two systems sort of work together in conjunction with the other things that the patient has to do to make those systems work to control their blood glucose levels.

So yes, tons of treatment.

- [Ardith] Tons of treatment.

- Tons of treatment.

- Now, there was a kerfuffle recently about the price of insulin.

Has it come down?

- In some realms, it has come down.

So the efforts have been successful.

But this has been a problem for us for really decades.

And it's really very unfortunate because patients.

In our fragmented medical system that we have, this medicine is covered, this medicine isn't covered or their copays are too high.

So, even our patients who have insurance are struggling 'cause they're underinsured to allow them to afford their insulin.

And I would add, their non-insulin medicines to help them to lower their blood glucose levels.

So it's been a battle for a long, long time and it's very unfortunate.

- Yeah, I can't imagine being poor and not being able to afford a medicine that you absolutely have to have.

- Right, I agree.

- It'd be terrible.

- I agree with you 100%.

If you take a look at a patient who has diabetes, and there are many faces of diabetes, so every case is different.

But for a lot of patients having diabetes is there 24 hours a day, seven days a week.

And so they have to think about it when they eat, when they don't eat, when they're active, when they're inactive, if they're on vacation, whatever, they have to think about this.

And then we ask them to take medications often and monitor themselves often.

I mean, these things I mentioned are great, but they're all work for the patient.

So then you ask them to do all of this, modify their lifestyle, "Oh, and by the way, you may not be able to afford your medicine."

- It's terrible.

- It is.

We need to do better.

- Does food really matter?

- Certainly matters to me.

(Dr. Salem laughing) (Ardith laughing) - Both of us.

- Yes, yes.

So yes, the types of food we eat really do matter.

We know we have carbohydrate, we have fat, we have protein.

Those are three big groups of food that we ingest.

And there are some foods called simple carbohydrates that turn into sugar right away when we eat them.

And for a patient who has diabetes, that can boost their blood glucose level very quickly.

And despite all the technology that we have, that makes it kind of harder for us to deal with it.

But that doesn't mean that it's not black and white where, "Oh, you can never have this."

For most of those foods, we just ask you to limit the amounts.

Nobody wants to hear or should have to hear, "Gee, you can never have a sweet again in your life."

That's not happening.

So we just have to kind of plan that and make the amounts appropriate and get it in with everything else that we ingest as a healthy meal plan.

And then, if we go off the wagon, so to speak, then we have to make an adjustment.

But it's really not the episodic kerfuffles that are the problem, it's really the ongoing habits, the things that we do night after night that may cause us problems.

- Dr. Salem, you've given us lots of good information.

Maybe you even saved some lives out there, who knows?

We learned much about diabetes.

Thank you for coming.

Thank you, our listeners, for joining us on Forum 360, with its global outlook and local view.

I'm Ardith Keck, your host.

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