good evening and welcome to doctors on call I'm Dr Ray Christensen faculty member from the Department of Family Medicine and biobehavioral health at the University of Minnesota Medical School Duluth campus I'm also a family physician at the Gateway Family Health Clinic in Moose Lake I am your host tonight for a program on Diabetes remember the success of doctors on call is dependent on you the viewer please call in your questions tonight or email them to ask at pbsnorth.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr David Hutchinson a family medicine physician with St Luke's Leicester River Medical Clinic Dr Jason wall a family medicine physician with the Duluth Family Medicine Clinic and Dr Mike Van schoy an internal medicine physician with Arcos health answering the phones tonight from the medical school our medical student Tommy gentle from Baudette Minnesota and staff members Katie Johnson from Duluth and Linda liskowis from Duluth and now on to tonight's program on diabetes good evening gentlemen and welcome Dave tell us a little bit about your practice I'm currently working with the St Luke's health system at the Leicester River Medical Clinic as a family doctor of 30 years Dr Wall good evening Dr Christensen I work at the Duluth Family Medicine Residency at the University of Minnesota program and I have the Good Fortune of working at both St Mary's and St Luke's and Dr Vans quick hi Ray Mike vanscoy here working Care Management as a medical director for Arcos Health it contracts with the Blue Cross Blue Shield of North Dakota for Medicaid expansion and Medicare Advantage folks thank you all for coming it gives us a wide base to work off Dr Hutchinson what is diabetes six ink into the point diabetes basically is an inability to control one's blood sugar blood sugar glucose is necessary for the energy and reactions in every cell in our body and nutrition that we take in is converted to glucose for that energy the pancreas produces insulin and secretes it in response to when we eat in order to keep blood sugar from rising too high and there are really two kinds of diabetes but the common theme between them is that we're unable to control our blood sugars when we're diabetic without some other assistance so doctor well what are the two types of diabetes that we're going to talk about tonight there's a type 1 diabetes otherwise known as insulin dependent diabetes and then type 2 diabetes somewhat known as non-insulin dependent and uh classically your type 1 diabetic is going to be somebody who's younger and due to illness and autoimmune they're going to be they're going to need to be very diligent about checking their blood sugars and injecting insulin on a daily basis otherwise they become sick with the condition they become acidatic and they have ultimately a condition called diabetic ketoacidosis and that can be fatal and the type 2 diabetic has more of the there's a wide age group but that is our classic that is where most uh Americans and most of the patients that we take care of fall into and they have a lot of these people will be taking insulin but they don't necessarily need it uh it won't it wouldn't be rapidly fatal if they wouldn't miss it and there's a whole pharmacopia of medications injectable oral and to to treat this condition so think of type one you need insulin to to live and type two you often need insulin to control it but you become sick more more slowly if you if you don't have that daily insulin very good thank you Dr Van scoy before coming in we were you were actually doing some looking online with some of the outcomes of diabetes and the concerns that we have with chronic diabetes do you want to tell us a little bit about what you found right no thanks Ray um for sure you know this is a this is a public health issue for all of America we have a high prevalence meaning the frequency with which diabetes occurs in our population if you hit the age of 65 and you're on Medicare you find that 30 percent people in Medicare have type 2 diabetes what Dr Wall was mentioning and of those most of them have complications already due to diabetes the complications can be poorly functioning kidneys poorly functioning nerves vascular disease which increases your risk of stroke and heart attack and poor vision so 20 percent of people in Medicare have diabetes with complications and 10 percent have diabetes without complications by the age of 65.

I think we could even add a little bit that the incidence of even type 2 diabetes which is largely genetic but also closely associated with obesity and degree of obesity um more and more younger and younger people even children are becoming type 2 diabetic because that's right nutritional factors and environmental factors lack of exercise in our general lifestyles I couldn't agree more absolutely there in the Medicare Advantage population 10 percent of people have either severe obesity or morbid obesity severe obesity is you know a BMI body mass index of 35 or greater and morbid is 40 or greater but David Deere Point half of people in America are overweight 50 percent are overweight um and if you were to have pre-diabetes which is a common precursor very common you know before people develop diabetes the national diabetes prevention program reduces your risk of evolving into Diabetes by 50 percent over a 10-year period of time and so a lot of that focuses on healthy living and choosing the right foods that are really of high nutritional value for yourself even though the innocence of diabetes is is rising and it's more and more of an epidemic it's really true that we have more and more hope now with intensive management tools both through lifestyle counseling and adjustment and medication use to really manage it so much better than we did 20 and 30 and 40 years ago it's um it's not a well there's much there's much greater hope for fully active lifestyle and for avoiding those complications that you alluded to now with current management tools being not the youngest one here and thinking back to the 60s and if you go back and look at the pictures from the 60s in the old yearbooks and any of the films from the 60s we were a different population then boy oh boy isn't that true yeah and I don't know what the numbers were back then as far as diabetes and I don't remember in practice just how prevalent it was I knew the juveniles the type ones but the type twos there weren't that many but that's evolved over time so Jason uh you've got a new let's take a type two a new type 2 diabetic comes in how are you going to treat them there's there's a lot of things I can't give you 20 minutes to tell me but you can give this a little bit here thanks Ray well ideally in medicine our partnership with the patient they do exactly what we want them to do and we know that's not the case it's kind of a it's a it's a partnership and so first is lifestyle exercise reasonable diet and then our first go-to medication is called metformin and then beyond metformin metformin's medication can cause weight loss it causes the blood your blood sugar to uh you can lose a little weight and it affects your pancreas so that your blood sugar doesn't rise so quickly and beyond that there are probably six or seven medications you could go on to some of the if somebody's blood sugar is really high we'd often start them right away on a basal insulin uh long acting once a day we'd start them on some of the newer medications that are called sglt2s other group of medications glp ones I can use the um there are a number of trade names you'll see them on TV and then are there are some of our old tried and true drugs like sulfonia ureas that we would use as well but it's really going to start with education lifestyle and then an ongoing relationship with your primary care team meaning you know potentially your your physician your pharmacist is often involved and perhaps even a dietary or a health coach a lot of difference in price in those medicines too yeah I I brought the prices in case anybody asks but yeah they're of course price is usually determined by Insurance co-pays but the new ones are not inexpensive no Mike why is it important to control the blood sugar well that's a great question Health Partners which is a great health system Down based in Bloomington Minnesota produced a report whereby in controlling blood sugars they were able to reduce the number of toe and foot and leg amputations and they were able to reduce the number of people moving on to dialysis with kidney failure they reduced the number of strokes and heart attacks and blindness so it was not just reducing mortality rate but it was also improving the quality of life and it's just it's just a a reflection of the fact that when you've got too much sugar circulating in the bloodstream it almost caramelizes I don't know if you guys think about being at the grill and looking at what happens when a layer of sugar kind of is on top of your food it caramelizes and damages the lining of the nerves of the blood vessels and other structures so that's why it's really important to keep it down you can show that people live and people live better being we brought the word foot in some kind person actually sent us an email ahead of time and certainly we encourage you to send emails for questions especially good when we start our discussion but this was about the charcoal foot this gentleman had a charcoal foot uh saw an orthopedic person or and was treated with an orthopedic boot he wore it for six months the foot was felt to be stabilized at that point and now he just uses an insert and the questions are what is likely to happen with that foot again is this likely to show up on the other side and are there things that he can do to preserve and keep this from happening so that's a whole bunch of things Hutch what are your thoughts so charcoal foot in general is an uncommon Advanced complication from diabetes which usually evolves through loss of proper innervation in the foot and then by some ways that are complicated to explain proper innervation is important for the maintenance of bony posture in the foot for the bones position relative to each other and this unusual complication can lead to the collapse of the structure and positioning of those bones and it's very painful and it's deforming and it Alters um one's physical activity ability it's very serious and often treated with bracing as the gentleman referenced so Jason as long as we're with feet why do we always look at feet what's important there as Mike had mentioned the main microvascular meaning small vessel damage from diabetes is your eyes your kidneys and then your nerves and so when you can't feel your feet you kind of get this stacking glove like sack like it can be a numbness it can be a burning pain and so if you don't have proper feeling in your foot you can imagine that you're going to have skin breakdown you're going to have foreign foreign objects that could get stuck in your foot but essentially you often you're very prone to developing ulcers on your feet not to mention there are the the blood vessels that supply nutrients to the to the toes and the foot can be compromised by diabetes so there's less blood flow and we have ways of testing for that as well with it's called an ankle brachial index um and so you know there's nerve damage there's less blood supply so you have chronic it's very easy one toe stub uh one you know splintering your foot and it can develop into an infection and a chronic ulcer and that's why we're always so we're always looking at the feet because when you have diabetes the risk of of losing part of your foot amputation infection is is quite high with that reduced circulation healing becomes more difficult and we pay a lot of attention very frequently in in clinical settings to any wounds on the foot on the foot of a diabetic because foot ulcers don't heal very well and we can't really stop walking so we keep putting mechanical pressures on those wounds which increases the difficulty of healing and as Dr well alluded to the the ultimate goal is amputation prevention loss of part of a limb was a really common complication for in diabetes there 30 and 40 years ago and it's uncommon now because we do so much of a better job at wound specialized wound care and preventive foot maintenance yeah and there are there are minnesotas and many states where like every diabetic visit there's a checklist of you know have they had their eyes checked have they had their kidneys checked have they had their feet checked and so I think we've gotten more systematic and so that's we're not it's not perfect but but we're at least aware of the issue my lesson is when I took the shoe off and saw the Thumbtack and the hole in the foot and absolutely no feeling so it's very very important that the shoes be looked at that people are very careful and here's where the eyes come in and here's where the all the rest comes in you made a good point about the shoes being prepared proper fit is really important in diabetics because abrasion and friction and if you have decreased sensation you don't know necessarily that that's happening as you were saying and those can lead to wounds that people aren't even necessarily aware of it they may be aware but they don't hurt very much sometimes and so and probably all of us at some point in our practice have had a poor patient come in with a diabetic needle in their foot that you know they were injecting their insulin they accidentally dropped it and it ended up in the carpet and yeah or there's somebody sewing in the house yeah because you just don't feel it Mike you've been out of this discussion anything you want to add into this one no I I totally agree with the discussion I'm still sort of stuck on your description of the 60s than I think you might be offering us a picture of yourself from the 60s maybe one of these days 160 pounds okay you see there you go then there was then there was internship and then everything went to Pieces after that um A1C there's a whole lot of questions coming in on A1C one of you guys want to tackle the what an A1C Mike you've been quiet for a while sure uh thanks hemoglobin A1c basically is just sort of a a blood test that gives an indication of what the average amount of sugar level is in your blood over the past three months it's a glycated hemoglobin so hemoglobin is a protein and when it's permanently attached to a glucose model it becomes a glycated hemoglobin and that's the blood test that we that we measure so now Dr Wall was mentioning that in Minnesota we've got a checklist of best practices in Minnesota Community measures which is our state's sort of data warehouse of best practices they like to see a hemoglobin A1c less than eight if you're in the world of uh Medicare Advantage and you're being measured by hedis standards they say that a poorly controlled diabetes is a score greater than nine so you have some disparity between who you know what people consider to be optimal control here in Minnesota we generally like to have it less than eight if we can that having been said is just an average value and you know I if I had diabetes I could be living in the 60s and 70s and then way up to the 240s and still have an A1C of 7.8 so I might look good on that blood test but half of the day I'm really low and half the day I'm too high and I'm really not healthy at either way so Dr Wall is going to be asking his patients whether your morning sugars what a year before lunch sugars what year before supper sugars and what are your sugars before you go to bed those are all important the A1C has is such a wonderful tool because it lets us look at an average blood sugar over three months right instead of a blood sugar at one point in time at least in the doctor's office and so checking that average blood sugar frequently gives us a good idea of what's the average level of control but of course you're right the day-to-day variations especially in type 1 diabetics when blood sugars can vary so widely that highlights the importance of monitoring at home in different ways as well it's also made diagnosing diabetes easier back in the day you used to have to have separate values on separate days and a glucose tolerance test um I I wanted to uh one of the most exciting things that I've seen because people just don't check their blood sugars and we now have they're called cgms continuous glucose monitors and some of them transmit directly to your phone there are some out on the market that you can link to all your relatives you can link it to your pharmacist your physician so the day is very close where you'll just have to put a patch on and you won't have to be poking yourself anymore and that gives us such invaluable data to say Hey you know you realize every day between six and nine your blood sugar is way out of control let's do something about it so and for continuous glucose monitoring has been so important for type 1 diabetics to help avoid episodes of blood sugars that go too low which is um instantaneously dangerous but why is it dangerous but low well our brain has to have glucose to function and if our blood sugar goes too low we become comatose or have a seizure or um you know and we fall and hit our head so we have to have adequate blood sugar and um but we but we don't want blood sugar that's too high which is why insulin is also important internal insulin from our pancreas is also important what's been so fun and interesting and primary care practice with continuous glucose monitoring for type 2 diabetics who who normally depending on what medications are on normally don't have to fear that hypoglycemia low blood sugar nearly as much as type ones do but the continuous glucose monitoring lets them flash their phone over that patch and they can it's a great source of self-education you can tell what your blood sugars do in response to what you just did or what you just ate it's it's immensely educational rather than having to poke your finger which we don't get supplies to do more than four times a day with the with CGM you can check your blood sugar multiple multiple times a day and it alerts you if you're going too high or too low so especially for children too it's incredibly reassuring for parents to know that you know they can just look their child can be 10 miles away across town and they can just be like yep you know Jimmy's doing fine so can a diabetic ever get off their medications yes the the short answer for in type 2 diabetes is yes and type 1 diabetes people have to be on insulin there's no way out of that one that's right yeah so and how do you do that David may I well one of you could do that go ahead well there are and we might shut you down for a while please do because I'll just go on Dr Walla alluded to some of this you know lifestyle adjustment is is the general way to control blood sugars without medications but that really entails about four different things you can exercise and burn calories and lower your blood sugar you can eat less take in less Fuel and have less ability to generate high blood sugars you can eat different kinds of foods which are less likely to raise your blood sugar so so-called lower glycemic index foods and that's an important part of diabetic education uh in the clinic and in nutritionist offices when people are diagnosed diabetic it's important to learn what foods are less likely to raise my blood sugar namely proteins and fats rather than starches and sugars and fourth and as important as anything else separate from all of those things you can lose weight so losing 10 percent of your body weight improves your body's ability improves your body's ability to respond to its own insulin in a in a much more ready way so we don't need as much medication or sometimes not medication at all at a lower body weight because our insulin is then working better some quick questions because we're going to run out of time Jason what's pre-diabetes how is it how is it defined pre-diabetes is defined by fasting blood sugar um right around 100 to 126 it's just below I think 126 is the diabetic cut off and there's an A1C range I think it's 5.6 to 6.4 you're asking me but anyway it's it's it's basically if you know if there's a bell curve of diabetics it's that that group of people that are trending from a laboratory blood sugar standpoint towards diabetes and we've called out pre-diabetes because it's a wake-up call for people to pay attention to their lifestyle and their blood sugar Mike Sodapop has a lot of sugar should we eliminate it from the diet and what about diet soda pop um yes we should eliminate all soda pops from our diet and after the show my brother is going to call me up not very happy with what I just said because he likes his Mountain Dew but yeah we should that's just got no place really um the diet sodas I think some people say there's no nutritional value to that and there's always a question about what is a sweetener in there there's some people with dietary intolerances to artificial sweeteners so in general I would just say stay away from anything except for carbonated water Hutch your active practice both of you guys are an active Pro oh y'all are I think what do you do if you see someone experiencing low blood sugar and dizzy faint Etc you try to get them some sugar some calories and the easy way to do that is with a little orange juice or a piece of candy in the pocket and then you have some handy in your in your clinic for sure I wouldn't know where to look yep we have kits that contain little glucose containing solutions that we can squirt in people's mouths yes gentlemen this has been interesting we did not get to medications we really need another show be fun to have you all back and then we should look at all of the new drugs and how they affect kidneys and so on I want to thank our panelists Dr David Hutchinson Dr Jason wall and Dr Mike Van scoy and our Medical School volunteers Tommy gentle Katie Johnson and Linda liskowitz next week please join Mary Morehouse for a special mental health edition of our program on Stress and Anxiety thank you for watching and good night [Music] [Music] thank you