good evening and welcome to doctors on call I'm Dr Ray Christensen faculty member of the Department of Family Medicine and biobehavioral health at the University of Minnesota medical school duth campus and I'm a family physician at the Gateway Family Health Clinic in Moose Lake Minnesota I am your host for our program tonight on diabetes remember the success of this program is dependent on you the viewer so please call in your questions tonight or email them to ask pbsn north.org the telephone numbers can be found at the bottom of your screen our panelist this evening are Dr Addie voro vorio I'll get it right yet the a family medicine physician at St Luke's Mount Royal and Lester River medical clinics and Dr Omar s sadiki a Internal Medicine specialist with St Luke's Internal Medicine Associates our medical students answering the phones tonight are Riley Berg from buiji Minnesota sabd Bravo of Lismore Minnesota and Tommy gentle from badet Minnesota and now onto tonight's program on Diabetes welcome hi thank you how's it going good to it's good to have you here tonight Omar you're new to the area uh welcome to duth you want to tell us a little about yourself um from I'm from I'm from New York I moved here about 14 months ago I'm I'm I'm board certified internal medicine and addiction medicine and I love it here so far and you practice where at St Luke's Hospital very good Addie we've done this before but tell me again so I am a native Delian I grew up here um I was in the cities for a while and came back and I practice at two different clinics two days a week at each for St Luke's well welcome back yeah Addie let's start tonight with uh just start out describing what diabetes is and start us down the road and we can branches we need to yeah and diabetes is a very broad topic so I would imagine we're going to be addressing a lot of things um with this but diabetes essentially is a a disorder of what we call glucose homeostasis so there's a certain amount of glucose that you should have circulating in your blood um at all times for management of our processes of our body but also to maintain sort of safe levels in the blood so we're not getting damage from those blood sugar levels and so diabetes is a disruption of that in some way and there are actually a couple different classes of diabetes and they're caused by very different things um we know that type 2 diabetes is typically what we would call starting with insulin resistance or the body doesn't really know how to use blood sugar properly because of obesity or other things going on in the body and diabetes uh type one is typically a disorder of the pancreas wherein autoimmune processes destroy our um insulin producing cells and we are no longer able to manage glucose in that manner so on type one you really need insulin yes that is the requirement so uh Omar on on type two what are some of the things that make type two diabetes happen what are genetic or other things some some are genetics a lot of it it can be hor hormonal changes leading to insulin resistance um so that's why some of the medications that we use help kind of sensitize the cells to insulin like metformin um but eventually some some patients will end up with type to diabetes on insulin as well and uh so there's a genetic component um weight's a factor too I guess that's one thing we have to remember also so lifestyle yes and it as I look back and watched and remember back to the 60s I'm old uh we were a lot thinner in those days uh what's happening with diabetes are we getting seeing more and more of it I think we're seeing more and more of it we're also screening more and more for it so I think we're trying to catch it earlier before it becomes something uh more out of control before it leads to some of the like heart disease and other things that can arise from it Strokes heart attacks so I think catching it earlier managing it earlier leads to the prevention of other diseases that can arise from it yeah and we are seeing it earlier as well um more so in younger populations so we're screening and seeing diabetes in younger adolescent populations that are obese um we're screening pregnant women more often and we're finding that women who have either genetic factors or obesity throughout their pregnancy are at high risk of developing not only diabetes later on but also throughout the pregnancy and the diabetes caused by pregnancy is called gestational diabetes that's caused by a totally different entity but it does still place people at risk for diabetes later on in life how do you diagnose diabetes I'm looking at you okay um I'll let you startes in a variety of different ways so you can essentially diagnose diabetes by a random blood sugar that is very high you can diagnose diabetes by a fasting blood sugar that is elevated but we always confirm that with What's called the hemoglobin A1c and hemoglobin A1c is a lab test that's dependent it's a molecule on our hemoglobin or our red blood cells and it's circulating in the body at all times and if you have higher blood sugars your actual hemoglobin molecule part of it becomes glycosilated or it has more blood sugar byproducts attached to it and so a hemoglobin A1c of greater than 6.5 is diagnostic of diabetes Omar where do you try to keep your diabetics at what level on A1C I I ideally below seven if we can below seven if we can but I like to see any kind of improvement in my patients CU I'm kind of and working from there it's hard try to make each patient kind of indiv individualized treatment it's hard to create a standard for everybody I want to take and step aside for a moment and welcome Ken rip apologize bad day bad day in the office welcome nice to have you here Ken is with uh CMH or Community Memorial Hospital Raider Clinic y you want to tell us a little bit about your practice Kim um a standard full practice family medicine and I've been doing it in been down in clo for coming up on 30 years so well welcome thanks the uh discussion the question discussion is getting back to type one and type two we kind of covered the differences um is there an increased risk of type two diabetes if I have a family history of type 1 diabetes Ken I'll just put you on the spot right away type one and type two are are very really they're very different disease States so your uh family history of type 1 does not raise your risk of type two now if you have type 1 or type two in your family you're more risked for that type but mostly it's type two that is more genetically linked in family we see it cohorted in a family when you when you diagnose diabetes now and someone knew uh what's your first treatment um Omar I'll look at you on this one depending on the A1C uh usually lifestyle modifications you know exercising more diet alterations something that's more manageable and we can repeat the A1C every three months so you can kind of in come back in three months and see where they're at and how how much improvements that they've made with lifestyle modifications alone if they hasn't made much of a difference then we would start them on some kind of medication what's uh your first thoughts on Diabetes treatment then yeah well well that's changed probably even in the past two to three years our mindset has changed and guidelines have changed as well so it used to be since the 9s when metformin came out that we would start metformin on every patient and that is still for a lot of patients the way to go for um medication that medication improves insulin sensitivity so it it allows our cells to use blood sugar more effectively and sort of fixes the initial problem found um there are people who either don't tolerate metformin due to some of the side effects like gastrointestinal side effects or who may be a better candidate for some of our newer medicines and and people are very familiar with the names OIC or monjaro and those are names of a class of medications that um do a lot of good things for blood sugar but also have a significant amount of weight loss associated with use and and inherently in type two diabetes if weight is one of the issues that additionally helps Omar your thoughts on how you handle it pretty similar pretty similar I do agree metform it still use pretty commonly because a lot of it's because of cost because mararo and OIC are still fairly expensive if your insurance doesn't cover it so kind of depends on um what we can do for the patient what are your thoughts on exercise Ken you're the exercise grw here uh so when someone when someone is diagnosed with type two diabetes in my practice for the first time I tell them this is your your chance to embrace this diagnosis or you can reject it if you embrace it that means you embra the lifestyle changes that it takes to get Improvement and I have had patients who've had you know seen their a1c's go from well above 10 down to seven with radical Lifestyle Changes movement um really helps unlock the key to type 2 diabetes which is getting the insulin that is in the bloodstream to work to get the blood sugars into the cell the more you move the better that system works the less you move then the system breaks down so if if people Embrace exercise and they can really see it make a change uh the continuous glucose monitors are really helpful for patients because they can see the impact exercise has on their blood sugar so um some people wear them all the time some people use them for a few weeks when they work with a diabetic educator which is very helpful and they can see the impact of exercise on their blood sugars but it takes time for the body to to fully you know re-engage you brought GL continuous glucose monitors in uh either you want to comment on those I mean I I think they're great I think they again gives you glucose monitoring throughout the day not just when you're poking your finger and checking it yourself which I also feel becomes cumbersome and nobody wants to poke themselves this is you kind of slap on kind of forget essentially for two weeks and you kind of check your check your triggers and get a better more accurate reading throughout the day when the fluctuations are so if you do need to make any adjustments that gives you better Insight there's the question here is I've seen reports that metformin can cause dementia and possibly develop uh overextended use uh what are your recommendations on the rec recommendations on use of metformin and I think we just kind of went through that uh what kind of side effects are you seeing with metformin I just open it to the GI mostly mostly GI isn't yeah mostly it's nausea or diarrhea um there's always going to be an association with these metabolic conditions and the medications we use for these metabol conditions because what increases your risk of dementia well having heart disease does having Strokes increases your risk of dementia having diabetes can increase your risk of dementia so it's really difficult to pick a part that a medicine causes this or it's being associated with this we still use metformin it's a great drug um the be we sometimes would see a a depletion of some of the B vitamins like B12 but that's treatable with supplementation Omar type one are there the question is what modern advances have we seen in fighting type one and we talked about the continuous glucose monitoring is there anything else on the horizon or thoughts or any of you but I lean toward you a little bit on this one trying to think I've seen a lot of patients use the continuous glucose monitor that interfaces with a pump now and so that's probably the biggest change we've seen is that the pump will automatically adjust your insulin level based on what your blood sugar is based on an algorithm and just a reminder to the question between type one and type two with type one you need insulin uh with type two you usually do not use insulin is that correct yes and do you see a lot of older people that convert or become type one uh in with their diabetes I think once in a while I've seen one or two maybe the question you're asking is do type two diabetics or do do older persons one diabetes can they go to type one or are type ones yes if if their pancreas just gets so tired that they're no longer producing much or any insulin they're not if you measured the specific test this C termal peptide to see if they're making any they're probably making some but they're making so little that they're basically a type one and type two or and and type ones can have an overlying type two meaning that if a type one gets obese and sedentary and they have a strong family of type two they can they can get resistant to their own insulin that they're injecting so we see that once in a while and sometimes we end up putting them on some medication to help try and change that Dynamic the interesting thing about diabetes at least type two is that if you're diagnosed after the age of 65 you're very unlikely to sort of progress as rapidly as um those who are diagnosed in their 40s 50s and 60s carb Counting anyone want to take that on yeah how the question is can you clarify carb counting and Insulin dosing I I think that takes the the scope of a diabetic educator and a dietitian to really measure what a carb is and how your own body response to that because carb counting and your insulin ratio depends on a variety of factors agreed good answer like that okay uh this this person's been a diabetic for 24 years and has been having trouble with high blood glucoses in the morning why might that be Ian it's hard and this is this is this would be a great one for a continuous glucose monitor because they could be just steadily Rising overnight whatever medications they're taking during the day wears off at night or they could be dipping at 4 in the morning and then their liver is pushing out a whole bunch of sugar uh in the morning and giving them a high so a continuous glucose monitor would be helpful there or unfor if they're up at 4 in the morning morning for whatever reason they can check and see where are they Before Sunrise yeah and there's a a hormonal effect that sort of happens in that early morning hour where we do see people go low um we also encourage people not to snack before bed because that raises your morning and early morning blood sugars the most along those same lines this person's husband is an insulin dependent diabetic whenever he is walking or exercising his blood sugar goes between 250 and 300 why is that so this is with exercises I read this question it it's probably difficult to know you know based on that one scenario but any stress to the body can R you know can cause an increase in blood sugar levels the counterproductive the counteractive thing is that exercise should help lower his blood sugar so it's hard to tell just from that one depends on how long the it lasts if theoretically should come down after the exercise is done as a body's kind of resetting itself y I agree um let's talk a little bit about the new medicines oics on the all over everything who wants to take that one on Ken you're sitting I'm in the hot seat I guess uh uh you're so zic is an injection uh it's once a week um some the injection is not painful you can get a little not there it does work on a system that plays with your satiety Center so people who are on it say you know what I just don't eat as much I eat you know half I go out to eat and I can only eat a half or a third of the plate and the rest I'm bringing home because I just can't eat it and so it is a good it does that is one mechanism on how it helps the body um lose weight it it works on other systems as well the nice thing is it does have cardiovascular benefits so one of the things that we've tried to do with diabetes and all diseases is okay we can change a number but do we affect outcomes and OIC in that class is building data that yes you're going to have less heart attacks and less cardiovascular disease which is a big deal to us because that's very expensive so um people who were on it um it's a very slow taper up and you have to be patient and people for the most part like it but the problem is is coverage is in in Insurance I've had many people who start it and are on it for a while and have to come off because of cost they hit the doughnut hole they can't afford their insurance their deductibles get just too high and they can't afford it because it is very expensive and because it's used as a weight loss Med we're seeing lack of availability and our pharmacies have really started like gapeing that keeping that I heard from a patient today that because she's not diabetic but she is overweight she can't get her medicines until all the diabetics have filled their medications which is a good thing it's a good um but it's it's hard to get um it's not a miracle you still have to do the work with diet and exercise it is when I get requests for multiple times a day and there also I think some black mark Market availability which is concerning too the concern would be is that actually FDA regulated medicine you don't know what you're getting no idea we don't have a long I don't know Omar have you read any of the studies on on OIC how long has how long has they followed it out we I know that there are some side effects that come with it some some side effects if you these contra indicated patients with P pancreatic cancer and thyroid thyroid issues but long as far as longterm side effects I'm not I'm not sure what the Studies have shown it's only been for years you don't want to be the first person to use a medication and you don't want to be the last person to use it but we don't know 10 years from now you know what do we do when someone loses a a great amount of weight and they're no longer diabetic but they're on OIC do we cut back on it what's our plan at that point what do we see in 20 years on someone who's used OIC for a period of time so that brings up the question can you cure diabetes let's say type two my answer would be yes theoretically yes theoretic and weight loss is the that that person will be forever metabolically changed so they're always at risk you don't go back to completely normal and the other new classes of drugs that we've talked about the flosin have been also game changers for us because once again these drugs have cardiovascular en renal protection which we were very surprised at I don't know about when you when that when the drugs first came out I'm like this drug is not going to be good and surprisingly it's been very protective to the heart lungs you get weight loss and it's a pill which for some people is nice yeah and what we're talking about is a medicine that you take Orly that increases the amount of blood sugar in your urine so you're wasting calories but you're also lowering blood sugar at that point right I thought it was going to gum up the kidneys and make your kidneys worse and so is there a brand name that you want to put out on that and I've been on Metformin for any for many years is there anything I can do to get to the get to the point where I no longer need to take the medication and we've talked about that it's with weight loss uh we've talked about cures for diabetes that really aren't um is there a point where you is there a point where you get in trouble with metformin that drug has been around for a long long time and is as far as I know is a very very safe drug I just open up the panel any thoughts not I've had patients who've been on it for decades without any kind of issue I've had patients who were diabetics on Metformin kind of weed themselves off of it and managing with diet and exercise but I don't it's hard it's hard to say it's hard to make a blanket statement of coming off metformin I have to be if the other changes are made with weight loss and exercise and A1C tracking and it was developed in the 1920s and then insulin came about we start of forgot about it um and we used another medicine instead of Metformin that was very similar that had some side effects like like lactic acidosis is what we always talk about so there's a theoretical risk of that and that's where acid builds up in your system and you get some metabolic changes um but we haven't largely seen that Ken you're the exerciser I think everybody's an exercis but I know you are circulation what can you do for poor circulation in the feet well there you already gave the answer movement helps we know that patients who have uh you know if there's actual poor circulation mean narrow blood vessels in your legs if you exercise to the point of pain several times a day your body will begin to create new paths around blockages that is one thing now you can also go you know get some testing done and maybe you do need a procedure to really open the vessel up but it but short of that those are the two majors there are some medications that are a little bit helpful but it's exercised regularly and it's un to the point of discomfort is what the the literature was saying is you got to work it until it it hurts a little bit and then back off and then start again sort of forcing your body to get better I've always said that angine and the cat angina in the calf is not dangerous so you just keep going unless a toe falls off yeah what about what about heart disease either one of you want to step in on that I again I think exercising is is is a is a good way to help improve your cardiovascular health I mean obviously stop you get chest pain shortness of breath but but do exercise more push yourself as much as you can to help improve those conditions we've kind of touched this before what type of increase uh in diabetes prevalence have we seen in modern society SE seen a lot I think a lot of it is due to the the the the availability of ultra processed foods and snacks and it is ultimately cheaper than eating healthy you know and it's easier to grab a bag of Cheetos than it is to grab a bag of carrots and lack of movement yeah smartphones mhm inhaled steroids um what what effect do they have on the A1C so they'll in some people um increase that there's a little systemic absorption of the inhaled steroids if you're on high doses or you use you know quite frequently we we would typically see the a andc go up really with systemic steroids or even intra um articular steroids joint injections yeah and we'll see that in patients who get a joint injection and their blood sugars are in the high 200s to 300S for a week or two after their injection um any other complications we should talk about we've got we've talked about vascular um infection infections a real problem I think sometimes uh so good diabetes control other thoughts on that kidneys eyes oh kidneys yeah kidneys important nerves diab neur yeah yeah if you want to get you know so an unfortunate complication to people who had diabetes either poorly controlled over a long period of time is that the nerves begin to break down a little bit and you can get just very bad pain and it's a difficult pain to treat there are some meds that are indicated for it that can be helpful but it is it is a tough one and I really it's you feel bad for your patients who have it because there's not we can't easily fix that the diabetes affects the small blood Val and the small nerves because things sort of get gummed up with sugar byproducts and other elusive things so I'm a young person what can I do to keep from getting diabetes stay a healthy BMI have a good balanced diet exercise yep that that is the best keep your stress level low you know sleep well how much exercise can don't drink your calories uh you know and that's a really good point yeah well that's right you know so it is um so Shameless plug my wife was a diabetic educator and I sent her one of my gestational diabetics and she tells me oh by the way she's drinking of qu a pop a day and once we eliminated that it went away so you know so the you know um so you know trying to move every day and I tell people make it fun make it interesting and and just any do a little bit more than you're doing now and that's and because I don't tell people you don't need to run a marathon but you just if you just increase a little bit it does build on itself I want to thank our panelists this has been a great discussion our panelists are Dr Addie vitaro uh Dr Omar squ and Dr Ken rip and our medical student volunteers Riley Berg sabde Bravo and Tommy gentle next week join Mary Morehouse for a program on Child and Adolescent mental health and thank you again for watching have a great night w