[Music] 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 and family medicine physician at gateway family health clinic in moose lake i'm your host for our program tonight on diabetes the success of this program is very dependent on you the viewer so please call in your questions or email them to ask at wdse.org the telephone numbers can be found at the bottom of your screen our panelists this evening include dr nahi kablawee a diabetes and endocrinology specialist with essentia health and dr john wood a family medicine physician with the essentia health and director of the family medicine residency program our medical students answering the phones tonight are sydney boike of crookston minnesota seth kimball from walker minnesota and lindsey simonson of owatonna minnesota and now on to tonight's program on diabetes gentlemen welcome appreciate you both being here dr wood you want to tell us just a little bit about what you do and a little bit of your background as we go into the program well yeah i'm the program director at the duluth family medicine residency program ray and i actually go way back i knew ray a long time ago i spent a little time in moose lake where rey has worked for many years and worked in grammare for many years as a family dock up there as well as other places and i can say one thing i've seen throughout my career is the both the immediate effects of diabetes the difficulties managing diabetes how pervasive diabetes is and how if you don't manage diabetes how there's a lot of downstream effects and also how the best way to manage diabetes is really a team effort between the patient the physician and the patient's family and surrounding and the patient's loved ones because it's really a team sport to do this correctly how true dr kablawy please tell us a little bit about yourself and your background um so and your work so i i'm an endocrinologist at essentia health i've been here about eight years now and so we see a lot of diabetes different types of diabetes as well as a lot of other endocrine problems and i have to agree strongly it is a team effort because we do even at our department we have lots of nurse educators and lots of dietitians that work with us to help our patients and to achieve the best outcomes for them yeah it's interesting several years ago i realized i needed the diabetes educators i couldn't do it anymore myself we kind of talked earlier about what we're going to focus on tonight and we've chosen diabetes type 2. john what is diabetes type 2 diabetes mellitus type 2 well diabetes is a diabetes sugar basically and diabetes type 2 is where it's a combination of impaired impaired hepatic glucose or insulin production but really increased insulin resistance the insulin that your beta cells and your pancreas are making just aren't as effective as it used to be you're making insulin but it's not working and it's not working because your body is more resistant to the effects of insulin insulin is an incredibly complex carbohydrate our in complex protein and what it does is it regulates sugar production and if you don't or regulate sugar levels and glucose levels and if you your body doesn't do a good job with that then you got microvascular complications which result in eye problems retinopathy heart problems you can get heart heart attacks strokes get kidney problems nephropathy you get problems with your circulation you can't feel as well resulting in amputations and so managing diabetes is incredibly important so and the type 2 diabetes i think our endocrinology colleague can probably say you know it's not quite as simple as type 1 and type 2 anymore but back in the day that was an easy way to look of it but in the u.s 90 95 of diabetes is type 2 so that's about what 30 million people in the u.s maybe 10 of the adult population it's a lot of people who have type 2 diabetes and many people might not know that they have even have diabetes you know because sometimes it can be somewhat silent before it so some years ago i've been around a long time longer than john there wasn't a lot of diabetes we didn't see a lot when i see television reels and things from the 60s we were a lot thinner back then can you talk to us a little bit about the pathology diabetes insulin the pancreas and some of that that falls into your work and where we need to go yeah so so diabetes of course um as dr woods said it really we divided broadly as type one and type two but he's right there is a lot more different types of it but it's basically one of two things you're either not producing enough insulin or your insulin is just as not as as effective because your body developed resistance to it so inside our our pancreas we have the beta cells uh which are the ones that produce the insulin and they respond to the blood sugars and the higher the blood sugar content on the blood they the insulin should go higher and to and it it works as basically the key to the gate to allow the glucose to go to enter the cells um glucose does not enter the human cells very easily so it needs to go through different ports and the insulin is what allows it to come in and then you know for various reasons obesity being one of them but the exact mechanism is not always clear increased obesity leads to increased or more problems metabolically with the sugars as well as the cholesterol and of course high blood hypertension and all the other factors but it basically makes it more difficult for the body to respond to the insulin so you end up having more and more insulin production more and more insulin production so initially you don't feel anything because the blood sugars are fine but your insulin is getting higher and higher and higher until it gets to a point where it cannot keep up and you start seeing the effect which is the blood glucose now stay is high and stays high and so sometimes we also have organ sometimes we sometimes we see the patients and we screen them because we're worried about their risk of diabetes especially if they're obese or overweight and they might not have diabetes yet but they might have what we call pre-diabetes which we can you know it's it's basically insulin resistance and sometimes it manifests as as you know noticing that after you eat the blood sugar goes higher than normal and stays high for longer and also impaired fasting glucose so even after not eating for a long time like on your morning blood glucose sometimes when you check and you find that it is higher than normal and so i think also one of the reasons why that we see a lot more diabetes is that we've been screening a lot more for diabetes compared to the previous years um and the definitions change based on how you know where we think we can start targeting and helping people before complications start happening so john what are the numbers that make diabetes how do i know if i have diabetes well there's a lot of different ways to diagnose it probably this in the office you know in the office if uh there's a an a1c which is a hemoglobin a1c and what they discovered was that red blood cells have protein on the outside of their cells that monitors your glucose levels and if you can in the glute the turnover of a glucose of a blood cell is about 120 days or three months or excuse me four months sorry my math isn't very good so we'll call it 120 days but if you can look at that a1c level if it's over 6.5 you have a diagnosis of diabetes and impaired glucose would be anything over six or you could do a random blood sugar anything over 200 or you could do a fasting blood sugar anything over 126. so if you wake up in the morning and your blood sugar is over 126 and it's over 126 two times in a row you haven't eaten anything you have diabetes if your blood sugar's over if your a1c is over 6.5 if you do some an oral glucose tolerance test which is really not done very often anymore where you give somebody a glucose load say 75 grams of glucose and then check their sugar a couple hours later if it's over 200 that means you're not as dr khalabi said you're you're resistant to the insulin that you're making because you should be able to clear a load of glucose and get your blood sugar back down to normal within a reasonable thing the other the other way to diagnose it is if someone presents with signs and symptoms of hyperglycemia like increased thirst you're urinating a lot you're losing weight and they have a random sugar of over 200 they have diabetes as well so there's many ways to diagnose it right probably the important thing is to get diagnosed and if your concern is to come in like if you're overweight if you have obesity if you have risk factors if you're probably less active than you should be if you have high blood pressure there's a family history of diabetes if you have hypertension heart disease you're often going to be screened anyway if you're a female and you have a history of gestational diabetes you're certainly at an increased risk for diabetes down the road and dr kalabowi when they say that i'm going to go to some questions when they say that blood blood sugars spike what numbers do they mean what what's spiking well um not very scientific term spiking we just basically refer to it that it's it's it's very high and now one thing that people should do to yell or most people should realize that is that naturally the blood sugars after it should go higher it just usually does not go beyond 200 after you eat and usually by two hours most of it has been cleared so uh most people it should be below 150 roughly after two hours so if it starts staying longer than that that's an issue now you have to keep in mind also the the what did how much did you eat uh how much did you do so these numbers are standardized based on for instance the the glucose tolerance test but if you ate a much larger meal it will take you longer much larger specifically carbohydrates will take you longer to actually clear that that glucose and so and that's why sometimes we have to utilize multiple different ways of testing before we figure out someone is really diabetic or not if they have diabetes or not and the numbers actually change depends on the situation you know so uh for for instance if you're elderly and more prone to having low blood sugars and have complications we do tolerate higher blood sugars because hypoglycemia or low blood sugars is more detrimental to the health compared to compared to the hype to slight hyperglycemia or slight elevation beyond the normal if you're pregnant to protect the baby and the mother of course but also the fetus and the baby we do actually use more stricter uh blood glucose measurements for control so so the it's basically situ depends on the situation but generally speaking yeah you shouldn't be above 200 after you eat a meal although again some diabetics or peripherals with diabetes especially type 2 will go beyond 200 frequently the question is with the treatments that we're giving them are we allowing it to come down um to where it should be so you both have wandered into gestational diabetes so i do have a question on gestational diabetes and this person is from from here in town asks what are some of the risk factors for gestational diabetes and this was a place where you might you do continuous glucose monitoring i know this is something you're interested in and um which one do you want to start on this um well obesity for you why not choose yeah you want to obesity would be certainly a risk factor going into it family history of diabetes would be another one for sure you know um i'd say those two things the prior history of diabetes you know in in a previous pregnancy of course is going to set you up for gestational diabetes that's why but the reason it you know there's not there's not too many things that actually obesity would be the biggest one that's why we screen people for diabetes ingestion is 26 weeks because you don't have any way you know there's risk factors but you really don't you've got to check everybody because even someone who's slender and you think they really don't have any risk factors they're very healthy they exercise et cetera et cetera still too they can be surprised that they are developing gestational diabetes because they're developing insulin resistance in pregnancy and you know being pregnant is incredibly challenging um endocrinological as well as physiological state and so different people are going to react what does that do to the baby if you have diabetes and it's not diagnosed or if it's not treated properly it can lead to macrosomia or a large baby when the baby's born which can also lead to complications at the birth like shoulder dystocia certainly an increase the fetus for you know all sorts of i'd say the mom has increased risk of hypertension but what we're really trying to do is make sure that the baby's born at a healthy rate to protect the fetus certainly at the time of delivery as well dr khloe now again your interest is in continuous glucose monitoring is this something that we do in gestational diabetes sometimes we have to uh because sometimes you know the we're not sure you know when we we usually utilize the finger sticks and of course a1c the typical diagnostic or screening tool is the oral glucose testing for patients who have not had diabetes before or had history of diabetes on occasions we do have to use continuous glucose monitor when the numbers are usually borderline and we're not sure are they are they spiking in between or how high is their blood sugar getting in between the finger sex checks because continuous so it is used on occasions but it's not part of the standard like we don't we don't have to use it for most people who have diabetes or who for most people who have gestational diabetes but there are situations where it it comes in handy and helpful i'm gonna change a little bit now john you brought up peripheral neuropathy i think earlier it was you i believe yeah um so how often should a person with diabetes have foot checks well they say yearly you know that's what the uh ustpf the u.s physicians task force says typically you know in practice i would recommend a little more frequently like every three to four months certainly on somebody who has neuropathy and neuropathy would be whereas i can't feel my my feet as like i used to they're kind of numb and tingly certainly if you have signs and symptoms of neuropathy you need to let your doctor know um and the big thing about neuropathy is it can lead to undiagnosed injuries to your feet leading to cellulitis or skin infection i've seen patients come in with thumbtacks in their feet they didn't even know they had them or pins and their feet that they've gotten so i always advise people that have diabetes is to check their shoes every day put their hands in their shoes to make sure there's not some object in there that they weren't aware of but typically you know once a year in a doctor's office but practically it's probably better to do it more often and the hard part is many people can't check their feet so it'd be nice if someone at home could help them someone could own could help them would be great that's why it's a team sport you know how dr dr how high does an a1c have to be before a physician should start a patient on insulin and is that where we should start well not unless again that that's that's a lot it's a big question so type 1 diabetes patients with type 1 diabetes do not produce insulin so really their treatment is insulin so type 1 is traditionally we thought of them as the young people and we used to call them we used to call it diabetes of the young but we realized now that a lot of also older people have diabetes that is type one so patients who have type 1 diabetes or diabetes due to immunotherapy or certain therapies that are like pancreatitis or pancreatectomy basically removing the pancreas or damaging the pancreas so there is no production of insulin you have to use insulin regardless of what the a1c was because they just need it now type 2 diabetes patients are a lot more complex because we we typically start with metformin for most of them being one of the all the safest cheapest medications that we have and then we tailor the therapy based on their situation and their a1c at the time of diagnosis does play a role so patients who come in with a very high a1c above 10 or 11. we're more likely to start some form of insulin on them uh patients who are more in the six and the seven eight and nine there's a good chance we can get them under control by just using oral medications or none there or none insulin injectables uh like jlp one agonists so it it depends on the situation it depends on on a lot of things we've been seeing you know more and more uh whether through guidelines or through what we do uh we try to talk because a lot of them have obesity so we try to use the medications that would also help with weight loss uh so glp1 medications have been uh have been very uh have been used a lot more and they keep getting used more and more often because they you know reversing the weight or causing weight loss actually can help reverse some of the diabetes and if some people can keep that weight off they might be able to get off of medications uh so we usually target in general for all that for all patients with their old type two diabetes um a seven percent to ten percent weight loss if they can achieve that that would be ideal and we also recommend for just generally for glucose health use is lifestyle modification and and exercise we do recommend 150 minutes of exercise weekly and it doesn't have to be very intense the intensity level is basically uh what's equivalent to a a brisk walk so if you take a brisk walk enough times in a week to get 150 minutes that would be great so so it starts with lifestyle modification that's why and and changing how much how many carbohydrates they eat what types of carbohydrates do they eat all of that affects their blood sugar so it's as i said it's a lot more complex than just deciding that this is not this number and you go ahead and start this this incident my first prescription is 30 minutes walking every day yeah no matter what's the matter with you yep so this gentleman had an a1c of 5 and his physician recommended stopping all of his medications now people sometimes will have a 10 or whatever and weight loss and using medications that will come down is there a point dr wood where you would stop all of those medications or not i would seriously yeah five is is certainly in the normal range yeah so that's i my congratulations to whoever phoned in that's uh you know a real success story there and that means that they're following whatever recommendations have been given to them because yeah there's a as dr khalabi spoke about the risk of hypoglycemia or low blood sugar is a real thing and you don't want to take medications that you don't need you can fall break your hip um or worse just by you know you could be driving and have a hypoglycemic spell if your if your sugars are controlled too tightly and so those are things you really need to think about sorry about the phone i thought i had it off um gastric bypass surgery does that help with type 2 diabetes it does it does tremendously help and a lot of times the effect that we actually see on controlling the blood the blood sugars is much earlier than even weight loss so a lot of times even going out of the hospital after their surgery some of their medications are held and and again it depends on how much we you know were they at before they even start what medications were they on how good was their control prior so it's not it's not uh one size fits all type of thing so but we tend to lower the medications as the patients are leaving partially because they also don't eat as much early on and and type two diabetes if you go fast if you fast you pretty much can get your blood sugars under control the problem is none of us can fast that for that long so you you have you end up eating and then your blood sugars go up again so so that's why again we start with dietary changes time of day what you eat and all that and the medications are really as are secondary to help the blood sugar control so dr wood a gentleman with a slimmer frame correct for example and still can that person still be at risk for diabetes sure yeah and is that more a case of diabetes type 2 or is that leaning toward i would hesitate to you can both jump in on it yeah i would hesitate i think i think we're probably at a part of our understanding where we're realizing it's more complicated than just dividing it into two or three subsets of diabetes like you know there's a what mature onset diabetes of the young where folks have type they've typically thought they had type 2 diabetes but they still were type 1 diabetes but they they really don't and we we don't really understand it as well so i would say a slimmer person ray that doesn't necessarily mean that they have type 1 diabetes it probably means that they may not be making insulin which is certainly predisposing you to type 1 but i don't think it's quite quite as simple as that yeah i agree it's it's not as simple as that of course um even a lot of times we we assume that someone because they're obese and presenting with diabetes that they're type two but then as we you know do more investigation and following them we find that they're type one but what we call latent autoimmune diabetes so these are patients who do have the immune problem autoimmune problem where your own body is actually destroying the beta cells and not allowing them to make insulin but unlike what we typically see with the young kids where it happens very quickly and they end up getting sick very quickly and present to the hospital unfortunately most of the time in these in those latent patients it actually happens a lot more slowly so initially they might look like type 2 and just have resistance problems then you figure out know that they're actually not making enough insulin and you have to go ahead and start insulin treatment and there are also medications that increase someone's resistance or can cause hyperglycemia even in someone who's who's slim so they will be somewhat like type 2 diabetes because it's an insulin resistance problem john what is considered a good blood sugar reading what's what where do you control to when you're treating a diabetic oh you know ideally below you know 126 140 you know really but it's a little more nuanced than that because in folks that are a little bit older you want to have a little larger threshold you can get away with a little bit more been a younger person where they have their whole life ahead of them and you want them to be successful and healthy you're really i'd say you're really looking for sugar below 140 and then you're going to be able to get an a1c down in the and you're looking at that a1c range you're trying to target to an a1c between below seven is really what you're looking at if you're thinking that diabetes diagnosed at a level of six and a half or greater if you can get that a1c around seven you're doing a pretty darn good job another question is how much water should i drink each day if i have diabetes leave it open um enough not to be dehydrated because that will that will differ i mean i cannot if someone has congestive heart failure we're going to have to be careful with how much they drink yeah um if they have liver problems or kidney problems we're going to have to be very careful so there is no specific recommendations to my knowledge yeah generally that feeling is to try to keep it where it's pretty clear yeah you're light yellow yeah whatever this has been a really interesting discussion i'm gonna have to bring it to a close there were a lot of questions uh you asked you mentioned a medication there's a lot of things that we could dive further into uh tonight uh and this could go on for a long time and it would be fun to do that it's almost like a medical school lecture so at this point forgive me on the monitors that one's not working i want to thank our panelists dr nahi kablawy and dr john wood and our medical student volunteers sydney boike seth kimball and lindsey simonson please join psychotherapist dina claibow next week for a special mental health program on addictions thank you for watching and good night thank you gentlemen for being a part of this thank you medical students and i want to thank linda liskowitz for her work [Music] [Music] [Music] you