Hi, I'm Dr.

Chris Aquiti, a hospitalist with Aspirus St.

Luke's and faculty member at the Department of Family Medicine and Behavioral Health at the University of Minnesota Medical School here in Duth.

I'm your host for our episode tonight on diabetes and other endocrine problems.

The success of our program is very dependent on you, the viewer.

So, please call in with your questions or send them to our email address, askpbsnorth.org.

Our panelists this evening include Dr.

Ryan Harden with the Gateway Family Health Clinic in Moose Lake.

And medical students are joining us tonight, Lizzie Nelson, along with another medical student of mine, Will Stone.

Our medical student answering our phones tonight is Olivia Hoff from Rushford, Minnesota.

And now on tonight's to tonight's program, diabetes.

Welcome you guys.

It's so glad I'm so glad you're here.

It's good to be here.

Yeah.

Why don't I start with um Dr.

Harden, why don't you just introduce yourself and tell us a little bit about your practice and then we'll talk a little bit about our students being here and the excitement of that in our program tonight.

So I uh I work at Gateway Family Health Clinic in Moose Lake, Minnesota.

And I also work in Sandstone at Gateway Family Health Clinic in Sandstone, Minnesota.

And I round at uh Essential Health in Moose Lake.

I also am in the department of family medicine at the medical school where Will and Lizzie are students.

Great.

Will and Lizzie were students of mine this fall in our our endocrinology course.

So, I am absolutely delighted to have them included.

We're not going to put them too much on the spot, but we we're giving our students in training an opportunity to talk about one of my favorite um topics, which is diabetes.

Maybe we could start with um just the story about diabetes because it's such a fun one.

Diabetes is a very interesting disease.

It's been around since well, before there were records of anything.

Um, diabetes comes from a Greek word named siphon because people who had it were noted to um have water pass through them just continuously.

So that's where that word comes from, diabetes.

Um, the most fascinating story about diabetes is the discovery of insulin.

And I love this story because it's such a profound um story about altruism and the good of humanity making a discovery for the benefit of all of mankind.

So in the 1920s there was a doctor named Dr.

Banting and he was actually an orthopedic surgeon who didn't like being a surgeon and he did some research instead and he went to a man named James Mloud and he said I'd like some dogs for my research and so he he got 10 dogs and a medical student named Charles Best and the two of them basically created diabetes in the dogs by eliminating their pancreas and they discovered that by it's a long process but By digesting the pancreas, they could um extrapolate a substance that was then called insulin and keep an a dog without a pancreas alive for a number of months.

And their first dog that was successfully treated was named Marjorie.

So, it's kind of a fun story.

So, um anyways, I'm boring the whole audience here probably.

We'll um maybe start with just some very basic questions.

So, I know that um our students learned and Dr.

Harding, whoever wants to answer this just fine, but when a patient comes into you and maybe they're worried because maybe their mom or dad had diabetes.

So, they might come to you as a a physician and they'll say, "Dr.

Harden or Lizzy and Will, when should I worry about having diabetes?

When would you test me for having diabetes?"

I think it's reasonable to test everybody who has a family history of diabetes for diabetes.

Uh that's fair.

Pretty much everybody should be tested for diabetes at some point.

Um, if somebody doesn't have diabetes, I think testing them for diabetes is a good talking point about how they can improve their health because certainly even though they don't have diabetes, they can improve their health and that uh gives us something to talk about in the clinic seeing what their blood sugar levels are normally.

Um, but if people have symptoms, if people are concerned that they have diabetes, if they have a family history of diabetes, if they have other illnesses that are associated with diabetes like high cholesterol, high blood pressure, um, atherosclerosis, heart disease, and stroke, uh, those are the people that should definitely be tested for diabetes.

Yep.

So, what kind of tests might we run?

Maybe our students will know some of those if you want to answer.

I mean uh A1C would give you a idea of where your blood sugars have been over the last 3 to four months.

Uh as well as your blood sugar lets you know like where you are in that moment in time.

So um any other tests that you would Yeah, I would say a fasting blood glucose where you go to the doctor in the morning, haven't eaten anything overnight, hadn't had anything for breakfast, and you go in and get your fasting glucose.

You want that to be below 125 for what we're saying for diabetes.

Good.

And you mentioned the A1C.

I think that's a really good talking point for our audience.

Um, so an A1C, what is that exactly?

Can you tell me what that is?

Is the average blood glucose level over three months.

Good.

Y I remember when I when I teach that at the school, we always talk about the red blood cells in the body carry the little glucose molecules around kind of like a taxi cab.

And so the amount of seats that are taken up on that red blood cell, that taxi cab, it is basically the number that equivalates into what the A1C is.

And so an average A1C maybe would be about 5 point less than 5.4.

And if you're above 5.4 to roughly 6.4, then we call you pre-diabetes.

And then 6.5 would clinch your diagnosis.

So it's a really important test to know.

I I'll just add to that that that checking somebody's A1C is how we one of the ways in addition to the other ways that you mentioned that we diagnose diabetes.

It's also how what we use to track diabetes to see how somebody's blood sugars are responding to treatment.

So you you can diagnose somebody with diabetes by checking an A1C, but it's also commonly tested to make sure that your their control is where you want it to be.

Such a nice reminder.

Yes.

So since we we know it's the measurement of that red blood cell and the red blood cell lives for three months, we usually don't test it more frequently than every three months.

And if you've got really good control, it might be once a year, twice a year.

So good point.

All right.

Um what else?

Oh, why don't we just also mention that every woman who is pregnant gets tested for diabetes.

Um maybe we can talk just a little bit about why we do that and um what we're looking for.

You know, why do we test pregnant women?

Does anyone want to one want to field that?

We're checking for gestational diabetes, which can be a complication with pregnancy.

Yeah.

And so it can cause a lot of complications, right?

Can be hard on the baby and make for a tougher delivery.

So, um so we would test every um and we do that a little differently.

So, how do we how do we do that?

We don't do their A1C necessarily.

Pregnancy is only nine months, right?

Thankfully, and so, um, we we do a different test.

And does anyone know what that is?

The glucose tolerance test.

Good, Lizzy.

I'm glad that you can talk toward that.

So, that's where they drink like a really sugary almost like a soda.

I've done it.

probably I'm the only one here that has, but trust me, it's the worst soda in your whole life that you will drink.

But anyways, um so we test for gestational diabetes.

Um what about let's pretend um this just happened to me this week.

I had a person come in with a heart attack.

Um it was kind of a classic presentation.

and the person had chest pain and um when they came in we admitted the patient and their EKG was okay and their tropponins at first were okay but it was a compelling story and so in that case we admit them because we're worried about them and we rule them out for heart attack but we want to check them for risk factors so is it appropriate to check an A1C for example for that patient what do you you guys think?

I would say so.

Yeah, I would I would agree.

Unfortunately, a lot of people get diagnosed with diabetes when they get admitted to a hospital because of a complication of diabetes.

So, a lot of times people will get diagnosed with diabetes when they're admitted to the hospital for a heart attack or a stroke because they haven't engaged the medical system previous to that to be tested for diabetes.

So, there a lot of people have diabetes and and they don't know they have it.

Um, I had a patient a couple weeks ago who came in just for a regular routine physical, a young, healthy um, man that was not overweight at all and his A1C was probably the highest I've seen and it he did not have any symptoms at all.

So, again, it's a good idea if you're concerned at all or if you have a family history or risk factors to be screened for diabetes.

I agree.

Um, this plays into one of our wonderful questions which I thank the audience for.

Um the the question is what are the early signs of diabetes?

I guess we could break this into two types of diabetes because there's type one and type two and we maybe should have started there but um actually we could have started there with my story about the dogs but too late now.

Why don't we explain what type one is and how it presents and then type two and how that might present because they can present quite differently.

Correct?

Do you guys feel comfortable answering that?

Okay, sure.

Go ahead, Will.

Uh, so type one is uh sort of the body is attacking the pancreas which produces insulin and so insulin allows for sugar to get into the cells which is where we want it to be so that we can power the cells and power our bodies.

Um, so I would start with that as type one if you want.

So in type one, if the cells of the pancreas are attacked, so those are to be like a nerdy scientist, those are called your beta eyelet cells.

And I could go into the whole history of that, which is kind of fun, but maybe our show isn't long enough.

Anyways, okay.

So let's pretend they're attacked actually.

So they're destroyed almost to the point where they have 20% left.

So almost 80% are destroyed before people really have symptoms, which is fascinating if you think about it.

There's a lot of reserve in the human body which wants to live and totally wonderful um part of life.

But okay, so if the pancreas of a patient with type one has a situation where they're not secretreting insulin any longer, what kind of symptoms would they have?

I think common first presenting symptoms would be um increase in thirst.

So they're drinking water all the time.

Increase in frequency of urination.

So maybe waking up multiple times throughout the night to get up and go urinate.

Um as well as um increase in hunger as well.

So the nerdy terms would be polyypsia, polyphasia, and um polyoria.

Thank you.

Good job.

I love using fancy funny terms.

Some of that we could end the show with our favorite medical term.

Anyway, so those are early signs of type 1 diabetes.

I agree.

They can present with weight loss, abdominal pain.

Sometimes they'll get sick and actually present in something called DKA.

And DKA actually can be lethal in up to 10% of patients.

So it's a medical emergency.

Those patients are always admitted usually to the intensive care unit.

There's a lot of electrolyte derangements that we worry about and it requires a a physician who's quite attentive to detail taking care of a patient with somebody who presents in diabetic ketoacidosis whether it's their initial present presentation or if they have type one and and then they present because of an injury or some other precipitating factor.

Okay, really good.

How about type two?

Dr.

Harden, how do you have your type two patients present?

I would say the majority of my type two patients present without any symptoms at all and we will catch their their diabetes by doing routine screening based on risk factors or coorbidities which means other diseases that they have that might be associated with diabetes.

Um if people have type two diabetes they might have again excessive thirst.

They're thirsty all the time.

They're drinking more than typically they're used to.

They're urinating a lot.

they're getting up at night to urinate, they might have an unexplained weight loss or weight gain.

Actually, could it could present as weight gain, but I would say the majority of my patients with type two diabetes are diagnosed, they have no symptoms.

I agree.

As an internist, more often than not, I just get it on an annual screening.

Maybe I'm suspicious because the patient might have other risk factors like family history, a sedentary lifestyle, maybe dietary, which there is a question about that I'll get to.

Um, and then for sure weight related.

Um, it's a very much a weight related disease for type two.

Um, Peggy has an a very fast a very great question.

So, I want to ask this.

What risk does gestational diabetes pose to a woman later in her life?

and what lifestyle modifications can she make to prevent those risks?

So, I'm that's a great question.

I'm glad that question was asked.

I'll just add one thing to the one of the biggest risk factors for gestational diabetes is fetal macrosomia, which means the baby is larger than it would be if if the mother didn't have diabetes.

And that can lead to some risk, you know, risk associated with with delivery.

But women who have gestational diabetes should absolutely be screened regularly after they deliver because their risk for developing type 2 diabetes is much higher than the average population.

So I would say every 1 to three years they should have an A1C to make sure that they don't uh develop type 2 diabetes.

And the other part of that question, how can they prevent it?

Regular exercise, healthy diet, maintaining a healthy weight and a healthy lifestyle.

and and they can probably prevent from developing diabetes ever, right?

Which leads into the question I promised about food.

I think it's a good one.

Can you eliminate diabetes by removing processed foods from your diet?

I would say I wouldn't focus so much on processed foods, but um diet plays a huge role in diabetes.

I mean, if people eat a well- balanced, healthy diet high in fruits and vegetables and exercise regularly, uh, if they're diabetic, they can become non-diabetic or at least have their diabetes managed without medicines or they can prevent diabetes.

So, instead of focusing specifically on processed foods, I would focus on low calorie foods and uh, diet high in fruits and vegetables.

Very good.

Yep.

Watch your calories, eat healthy things.

Mhm.

Um, I once heard somebody say, "If it comes in a box, it'll put you in a box."

Anyways, okay.

Doug from Finland, can you talk about insulin resistance and how that can change over the course of diabetes?

So, insulin resistance, maybe we should talk about what that is and then um how that plays into developing diabetes.

What is insulin resistance?

You have receptors on the cells that sense the insulin.

So insulin resistance would be the cells becoming less sensitive to the insulin, less reactive.

Right?

So it's seen mostly in type two diabetes.

I always told you guys that it's kind of like the old woman who lived in the shoe who had so many children, they no longer listen to their mother.

So there's so much insulin running around that the cells become desensitized.

They don't listen any longer just like those children.

Anyways, great question, Doug.

And then as that insulin resistance builds and gets worse, then of course there's lack of regulation of that blood sugar.

The blood sugar levels raise higher and higher and then of course that will give you a higher A1C, more risk of both what we call microitic disease and macroitic disease.

Maybe that's a good thing to talk about different types of complications of diabetes that we worry about.

So I just used two words.

So microitic, you want to talk about those?

Those are like the smaller blood vessels.

What kinds of things are those?

Feel I'm sorry.

I mean to be a feel like a teacher.

The um so the complications of having blood sugars that are inappropriately elevated is dangerous to blood vessel health.

Small blood vessels, medium blood vessels, and large blood vessels.

So the large blood vessel diseases that we worry about as a complication of diabetes are heart disease and stroke typically.

Uh the small blood vessel diseases that we worry about as a complication of diabetes are um blood vessels in the kidneys um and blood vessels in the retina of the eye.

So that's why you can get ocular complications or eye complications and diabetes if it's not well controlled can affect the eyes and the kidneys.

at small vessels and it can also affect really small blood vessels that are associated with nerves and poorly controlled diabetes can cause peripheral neuropathy.

Yes.

Which I think brings us to a really important point.

If you have diabetes, you should always look at your feet.

Yeah, absolutely.

So, um here's a kind of a a question about medication, which I think is a good one.

What is the importance of monitoring B12 levels in someone taking metformin?

We know there's a correlation.

So, someone out there knows something.

Does anyone want to field that one?

Well, metformin is very commonly prescribed to treat type two diabetes.

In fact, it could be argued it's the number one medicine that you put people on when they have a diagnosis of type two diabetes.

There are some new medicines that are coming out that might challenge metformin as the first medicine that we give people with type two diabetes, but metformin interferes with your body's ability to absorb B12.

So, people who are on metformin should have their B12 monitored probably yearly.

Yeah.

I have to say, I've practiced medicine for 26 years.

I've I think I've seen it once or twice.

Have you seen it more than that?

It's I I wouldn't say it's common.

It's a surprise when I have somebody with a low B12 level usually, but um that's why we screen for it because it's people don't have symptoms when their B12 levels are low.

So, we screen for it, right?

Sorry to interrupt.

Now, with alternative choices might be something to think about, but good.

Here's a great question.

I'm not sure who asked, but it says, "Is diabetes a risk factor for dementia?"

So, we were just talking about vascular disease.

I would I would say definitely yes it is.

Um there's multiple types of dementia.

So it depends on what type of dementia you're referring to, but um there there's a type of dementia called vascular dementia where the blood flow to certain parts of the brain is affected by the um health of blood vessels.

And as we talked about before, if somebody has poorly controlled diabetes, that can affect the health of blood vessels.

So um absolutely poorly controlled diabetes is a risk factor for certain types of dementia.

Right.

Good.

So yeah, I would have to agree it is a risk factor.

It would be something that would be on my mind for treating patients with um diabetes.

So the better you can control your diabetes, the less likely you are to develop the complications such as microvascular neuropathy, kidney disease, eye disease, which you should get your eye exam every year.

and then um ma macrovascular heart attacks and strokes and things like dementia.

So um I think uh let's see uh we're out of questions for the moment but um what I would I'll circle back to the question about insulin resistance.

I think that we all as we age develop a little bit of insulin resistance which means your the cells in your body don't respond to insulin.

And earlier we talked about the mechanism of type 1 diabetes.

So type 1 diabetes is caused by the absence of insulin.

So those people who have type 1 diabetes need insulin.

Um type two diabetes is also referred to as insulin resistance.

And um people with insulin resistance don't necessarily need insulin to sometimes they do but not always do they need insulin to manage their diabetes.

So that's really the big difference between type 1 and type two diabetes.

Type one absence of insulin, type two resistance to insulin.

Thank you.

That is such an important clarification.

And um they're they are treated differently.

So, uh, sometimes type two gets to a point where the insulin actually is kind of burned out of the pancreas because what happens is the pancreas responds in kind to insulin resistance by making more insulin.

And so the pancreas is over overloaded and so then eventually it stops creating insulin and then they behave a little bit more like a type one where they need insulin.

But very very ex um exciting interesting diseases when you talk about endocrine um illnesses.

So um maybe we can talk a little bit then about I was going to finish.

We never finished our story about my favorite story about insulin and that is when um Frederick Banting discovered insulin and finally gave it to a patient.

There was a young man named Leonard Thompson who was 14 years old and Leonard was dying of diabetes type one and every parent knew if they had a child diagnosed with diabetes that they would lose that baby that child.

And so um Leonard Thompson's father found out about the physicians in um in Thunder Bay.

No, I'm sorry.

Um yeah, no, where were they?

They were in Ontario somewhere.

Yeah, Canada.

Hudson Bay.

The Hudson Bay.

So anyways, um he brought his son and he um begged the physicians to allow him to be the first human to receive insulin and he was.

They first tested it on themselves and made sure it was okay and it worked for Leonard Thompson.

It kept him alive for for the next day and the next day and so on.

And I believe he I'm forgetting how old he lived to be.

But anyways, he lived longer than had insulin not been present.

um and I'll add to that that in modern medicine if people have type one or type two diabetes and it's controlled appropriately they can live a normal life.

Yep.

That is very true.

The fun part is too that um the physicians who discovered diabetes decided that they were not going to make a million dollars from it.

They were going to give it to the world and so they sold it to the world for $1, which is the fun part of the um the story.

They were so altruistic and giving and kind that they weren't about making money, but they were about um about just making sure that we were progressing in terms of medical progress.

So, we only have a little bit of time left.

Is there anything that anybody wants to say about one of our favorite diseases to to care for?

I I mean I'll just reiterate that if people have diabetes type one or type two, as long as it's managed appropriately, they can, you know, live a normal life without any significant symptoms.

I agree.

So, it is definitely team effort.

So, we're going to wrap up tonight and I really would like to thank our panelists, Dr.

Ryan Harden, Lizzie Nelson, and Will Stone.

Please join Doctors on Call next week where I will be joined by regional experts for a panel discussion about lung and respiratory problems with a panel of experts from around them region.

And if you're looking for more tips, tricks, and conversations around health and wellness in the Northland, make sure to check out Northern Balance on PBS northern.org and on our YouTube channel.

Thank you for watching and joining us for season 44 of Doctors on Call.

Have a great night.