In this Physicians’ Roundtable, Eisenhower physicians discuss the medical community’s current thoughts on and approaches to diabetes – including its development, treatment and implications for overall health. The discussion includes Endocrinologist Helen Baron, MD, Arbatel De la Cuesta, MD, Board Certified in Internal Medicine, Marielena Cid, MSN, RN, CDE, PHN, Manager, Diabetes Education Services, and Sherri Mason, RD, CDE. Justin Thomas, MD, Board Certified in Pulmonary Disease, Internal Medicine and Critical Care Medicine, moderated the discussion.
DR. THOMAS: We’ll begin with a little etymology: Where did diabetes get its name?
DR. BARON: Diabetes is a reference to a disease process that was first described by the ancient Greek physicians, so “diabetes” has a Greek origin meaning “increased urination.” There are two types of diabetes that were described in medical literature, diabetes mellitus and diabetes insipidus. Mellitus refers to honey. The ancient Greeks first identified diabetes mellitus in individuals that had a wasting disease in part due to this chronic urination, but their urine would attract ants. Hence the name diabetes mellitus — honey urine. Diabetes insipidus — insipidus means “without end.”
DR. THOMAS: What types of diabetes mellitus exist?
DR. BARON: There are four types of diabetes mellitus. There’s category one, which is autoimmune diabetes, also known as Type 1 diabetes or insulin-dependent diabetes. There’s category two, insulin resistant diabetes, which used to be called adult onset diabetes.
Category three is gestational diabetes, a special type of diabetes that exists just within the second and third trimester of pregnancy and then resolves thereafter.
And then category four, which is anything else — drug-induced, pancreatitis, pancreatic surgery, and other medical situations like cystic fibrosis-related diabetes, plus transplant diabetes, etc. But the one commonality that all diabetes mellitus shares is hyperglycemia — an inability to maintain normal blood sugar control. Diabetes is a story of not enough insulin on board to get the job done to maintain good blood sugars.
???????DR. THOMAS:What are the symptoms of diabetes?
DR. DE LA CUESTA: Typically, patients will present with no symptoms at all. Diabetes is often found in a routine screening on their blood test. Unfortunately, it is silent in most people unless it is quite uncontrolled and has been going on for a while. The patient may say, “I’ve been urinating all the time and I don’t know why. Maybe I have a urinary tract infection?” At that point, we start a workup and we’ll discover that it’s actually diabetes. But mostly it’s detected in general routine screening.
DR. THOMAS: Is diabetes genetic?
DR. BARON: It actually depends on the type of diabetes. Type 2 diabetes has a profound genetic predisposition. The prevalence of diabetes in this country is 10 percent — one out of every 10 adult Americans has diabetes. In essence, our baseline risk of developing diabetes is 10 percent. However, if you have one biological parent with Type 2 diabetes, you have a 25 percent lifetime risk of developing diabetes. If you have two biological parents with Type 2 diabetes, you have a 50 percent lifetime risk.
Type 1 diabetes is different. There is a genetic predisposition to a much lesser extent. If you have a single parent with Type 1 diabetes, your likelihood of developing Type 1 diabetes is less than five percent.
DR. DE LA CUESTA: Many understand diabetes as caused by environmental factors such as diet, exercise or even prenatal exposure to high levels of insulin, rather than genetics.
DR. BARON: That’s an excellent comment. Type 2 diabetes is imprinted on our DNA. It is based at a foundational level on a genetic predisposition for progressive beta cell failure. Like everything else in life, it’s a combination of genes and environment — how we were born, and then how we choose to live that life.
For numeric simplicity, let’s say your genes gave you a genetic maximum lifespan of a hundred years. That means that if you do everything right, your telomeres [a protective structure at the end of a chromosome] live to their ultimate extent and you’ve got a hundred years.
But even with lifestyle, you’re not going to buy yourself more than the hundred years. What you can do with lifestyle is give yourself fewer years if you don’t live right. Diabetes is an example of that.
Imagine that you have a genetic predisposition of a life span of a hundred years, but also a genetic predisposition for progressive beta cell failure (the cells in the pancreas that produce insulin). That means that your beta cells are now going to last maybe 80 years. Still not bad, but less than your ultimate lifespan.
If you don’t do well by your lifestyle, your cells may only give you 70, 60 or 50 years.
That’s where we come on board — to help you get your genetic maximum. We do this with therapeutic lifestyle changes such as daily aerobic activity, medical nutrition therapy, maintaining as close to an ideal body weight as possible, and not smoking — doing the right things for our health to get the most that we can get out of our DNA.
DR. THOMAS: Type 2 diabetes seems to be a combination of genetics as well as environment and life choices. What about Type 1 diabetes? What creates that?
DR. BARON: There is a genetic predisposition, an autoimmune configuration that’s going to predispose an individual for autoimmune diabetes. And then there is an inciting event, something that triggers this autoimmune response, and we don’t know what that trigger is.
DR. THOMAS: For whom and when would you recommend screening for diabetes?
DR. DE LE CUESTA: The American Diabetes Association recommends all adults age 45 or older be screened for diabetes. Clinicians should also consider screening younger patients with risk factors such as sedentary lifestyle, obesity, family history, gestational diabetes and high-risk ethnicity. In my practice, every new patient who comes to my office is screened.
DR. THOMAS: We often hear about the hemoglobin A1C. Would you please describe what that is and how it is used to diagnose diabetes?
DR. BARON: The hemoglobin A1C test is one of the ways we can diagnose diabetes. We have many tools for diagnosis. It starts with laboratory values, blood sugar checks. You can check fasting blood sugar and postprandial [after lunch or dinner] blood sugar. We check hemoglobin A1C and we can do an official oral glucose tolerance test.
Hemoglobin A1C is an intriguing marker, because this one blood test gives us a three-month average of blood sugars. It’s weighted a little bit differently, so that 50 percent of the A1C is reflective of the most recent 30 days. It is a great test to give us average glycemic control numbers. If you don’t have diabetes, that number is typically less than six percent. Between six and six and a half percent is prediabetes. When it’s higher than that, we diagnose you with overt diabetes.
DR. THOMAS: Diabetes is more prevalent in certain ethnic groups. Tell us about that.
DR. BARON: In the baseline population in the United States, the prevalence rate is 10 percent. If you look at Caucasians, it’s seven percent. If you look at Native Americans, it is 15 percent, and African Americans, Latinos and Southeast Asians are a little bit less, but right above the 10 percent line.
DR. THOMAS:: You feel strongly that diabetes will become a pandemic in our lifetimes, is that right?
DR. BARON:: Yes, we will live to see the epidemic of diabetes become the pandemic of diabetes. By the year 2050, the CDC has predicted that our prevalence rate of diabetes in this country may be as high as 30 percent, which means one out of every three to four adult Americans will have diabetes.
Right now we have 30 million adult Americans with diabetes and 85 million Americans with prediabetes. And what does prediabetes become when it grows up? It becomes overt [most advanced stage] Type 2 diabetes.
DR. THOMAS: Let’s say I have diabetes now. Why does it matter and what does it mean?
DR. BARON:: Diabetes has complications — microvascular and macrovascular. In other words, quality of life complications, and length of life complications.
Diabetes that is uncontrolled is intimately associated with microvascular complications. That’s the ability to see, to pee and to feel — diabetic retinopathy, nephropathy and neuropathy. And if we control the blood sugar, we minimize those complications tremendously. Going blind, going on dialysis or not feeling your feet anymore won’t kill you, but they’ll significantly impact your quality of life, and it is valid and important to prevent those.
If we talk about length of life complications, those are macrovascular disease complications. That’s what actually gets listed in the cause of death on the death certificate — heart attacks, strokes and peripheral vascular disease. Those are entities that will truly cut down the lifespan of the individual with diabetes. So, it is our goal to provide good health — not just length of life, but quality of life.
DR. DE LA CUESTA: The biggest problem with diabetes is that it’s silent. Patients don’t feel they’re hyperglycemic. Because it doesn’t hurt or cause noticeable damage initially, it’s easy for us to neglect and underappreciate the seriousness of what’s going on.
MARIELENA CID: It’s amazing when we see patients in the hospital with glucose sugar over 800, which is extremely high, and they don’t have any symptoms. And often, they came in for something else and they say they feel fine. SHERRI MASON: Sometimes when we talk to patients after they come in for education, they might say they did feel tired or thirstier than normal or that they were urinating more frequently during the night. Many people don’t recognize the most common symptoms of diabetes. They also might have intermittent blurry vision — blurry and then better.
DR. THOMAS: Does diabetes also put you at risk for infections?
DR. BARON: Most certainly. Blood sugar belongs in one of two places: in the cells feeding them so they can do their work, or in the liver. Those are the only places sugar really belongs.
When your glucose is in a circulating pattern, if the circulation is not going to the liver and not going to the cells, that’s where trouble ensues. Insulin is the key that unlocks the door to the cell that allows glucose entry. And if you don’t have enough insulin on board because of an absolute deficiency (autoimmune) or relative deficiency (too much insulin resistance), you can’t unlock the key to the cell and you can’t allow for glucose influx. And so it ends up in this persistent pattern of circulation.
That’s not good for the body because glucose sticks to anything that moves, and it will stick to the inside of the vasculature. It will stick to platelets, it will stick to red blood cells and it’ll stick to white blood cells, the cells in your body that fight infection. The white blood cells become so coated with glucose that they become deranged and you can no longer effectively mount an autoimmune response.
In effect, you have high blood sugar, you have diminished immune response and you’re more susceptible to infections.
MARIELENA CID: I also want to point out that recurring vaginal infections may indicate high glucose. Many times patients have diabetes and they don’t know it. Women with recurring vaginal infections should ask their physician to screen them for diabetes.
???????DR. BARON: And that’s exactly the purpose of us talking about diabetes. You can have this condition and live a happy, healthy, fruitful life. The key is maintaining the control of blood sugar.
DR. THOMAS: That’s a perfect segue into my next topic, which is the treatment of diabetes. What is the overall treatment or management paradigm of diabetes?
DR. BARON: We preach TLC, or therapeutic lifestyle changes, which are diet, exercise and weight loss. When that is not enough to manifest good glycemic control, and more often than not it is not enough, then we consider pharmacologic agents.
Type 1 diabetes is a very unique form of diabetes where, of course, you just don’t make enough insulin anymore through an autoimmune process so you go on insulin therapy from the beginning.
With Type 2 diabetes, we need to know how much insulin is on board and how much insulin resistance is in conflict with that insulin. We try to minimize insulin resistance as much as possible with medical therapy, with sensitizers like metformin, the most commonly prescribed medication for all of Type 2 diabetes.
The next level for insulin sensitization are other therapeutic entities like bariatric surgery, in particular the Roux-en-Y procedure, which is the only meaningful bariatric surgery procedure that actually affects blood sugar control.
DR. THOMAS: Other than medications, what other options are there for patients with diabetes?
DR. DE LA CUESTA: First you talk about diet and exercise. These are the basics. There are a lot of different ideas about what the most appropriate diet is for a patient with diabetes. For the most part, I recommend starting with eliminating simple sugars, particularly high fructose corn syrup. These sugars have become so prevalent in our processed foods and beverages that it should be viewed particularly for diabetic patients as an environmental toxin.
Next, I suggest implementing a plant-based whole foods diet rich in fiber and protein. You have to actively discover a healthier way to eat, but in the process you also have to enjoy life, and enjoy what you are eating. That’s the challenge, but it is completely doable when you put your mind to it.
In addition, I recommend regular exercise — the more the better. The goal should be one hour a day of mild- to moderate-intensity exercise or 40 minutes a day of moderate to high intensity exercise six days a week. It’s hard for many people to start at this level so I recommend working up to it and trying different activities until you find one you enjoy. With these lifestyle interventions, many patients can not only manage their diabetes but also reduce their risk of cancer, heart disease and all-cause overall mortality.
DR. THOMAS: Are there other metabolic derangements with diabetes? Such as cholesterol problems or other factors that may lead to some of these diseases such as heart attacks and strokes that we can control?
DR. DE LA CUESTA: Yes. That’s why I focus primarily on a plant-based, whole food diet. Cholesterol is only made in animals, not plants. Anytime we eat animals or animal products including cheese, eggs, and dairy, we take in extra cholesterol. In population studies, the difference between a vegan and omnivore diet corresponds to an approximately 20 percent difference in total cholesterol levels. More importantly, we also see a significantly decreased risk of cardiovascular disease, heart attack and stroke on a plant-based diet.
DR. BARON: I think there is no one-size-fits all in terms of diet. There are different dietary programs, and I feel that the one that offers the healthiest options for the patient and offers longevity for the patient is the best.
One diet that has the most universal medical acclaim, from endocrinology and from cardiology, is the Mediterranean diet, which is a plant-based diet. It incorporates very little protein from animal sources and it really focuses on what we call single ingredient foods, non-processed foods.
Make healthy choices like walking the perimeter of the supermarket. Don’t go into the interior aisles; that’s where the processed foods are. Buy single-ingredient foods. Shop organic if you can.
Minimize the processed foods. In particular, minimize fructose, which is found in sweet beverages, juice, Frappuccinos, and in packaged desserts. You actually find fructose in a lot of foods. If it’s packaged, it probably has high fructose corn syrup. My concern with a lot of these artificial sweeteners is that you consume them and your body thinks that it’s getting real food. Your body gets a little bit of an insulin reaction to having the perception of having something sweet and some food coming into your body. My expectation is that you will be hungrier than if you hadn’t had it. DR. BARON: We tend not to see a spike in the blood sugar, but you do stimulate a hunger response. The tongue communicates with the brain and you set yourself up for the secretion of insulin. But then there’s no sugar.
DR. DE LA CUESTA: When I tell people we’re going to make a dietary change, I say, “I want you to make a conscious effort one day a week. You’re going to look for a new recipe, something healthy that you like. Give it a try. If you like it, incorporate it into your weekly regimen. If you don’t like it, try something else. But you have to make that effort to try something new every week.” If you do that and you start teasing out these foods that you actually enjoy, you can build a healthier diet that isn’t restrictive.
DR. THOMAS: Can a primary care doctor take care of a patient’s diabetes?
DR. DE LA CUESTA: When a patient comes in to see me, it’s usually not just because of diabetes. There are four or five other concerns. Despite this, for most patients with diabetes, the primary care provider can do an excellent job; however, for complex patients and those for whom you cannot achieve adequate control, then the help of an endocrinologist can make a big difference. DR. BARON: I agree. I’m so grateful to work in concert with my primary care colleagues, because it does allow me that opportunity, within the context of a clinical visit, to focus 100 percent on their diabetes.
I wouldn’t be able to do that without my primary care colleagues. I think we provide an exceptional package deal for our patients.
DR. THOMAS: How frequently should patients with diabetes see their doctor?
DR. BARON: When we first see a patient, it may be that their glycemic control is less than what we want, so we’ll see them more frequently. We can see an individual weekly, twice a month, once a month, once every three months, all the way up to yearly. The follow-up is custom tailored to the patient’s needs and their glycemic control.
DR. THOMAS: Diabetes is really complex. There’s a lot that a patient has to think about, like diet recommendations, medications and more. There are risk factor reductions. Is there support for patients beyond doctor visits?
DR. BARON: Luckily, we have an entire team. Individuals can have their primary care provider, their diabetes specialist, and perhaps most importantly, our diabetes education team. We have certified diabetes educators and registered dietitians. Here at Eisenhower, we have a tremendous team, wonderful resources, and incredible support for our patients — not to carry them through this process, but to walk hand in hand to achieve and maintain glycemic control.
MARIELENA CID: I do want to highlight that Sherri is a certified diabetes educator, which is different from regular dietitians who may not know as much about diabetes.
For us, it’s important to help our patients understand diabetes and help them manage their medications. Managing diet, preventing complications and working with the physicians is vital. And Sherri is a great resource because of her expertise.
SHERRI MASON: Everyone on our team is passionate about what they do. We really care about our patients.
People should also know that what we offer is a covered benefit by most insurance providers and we will help them through it.
MARIELENA CID: If you don’t have insurance coverage, we still provide three free classes in English and Spanish for the community.
DR. BARON: And don’t we offer a program for individuals who have prediabetes?
MARIELENA CID: Yes. We have been recognized by the CDC for Diabetes Prevention. It’s reimbursed by Medicare and we’re trying to get other insurances to cover it. But if their insurance doesn’t cover it, we still allow them on the program because the goal is to prevent or delay Type 2 diabetes.
The program is 12 months. Participants have a goal to lose five to seven percent of their weight when they start. We meet weekly to provide support and keep them accountable. We have patients who started two years ago, who tell us they’ve continued their lifestyle changes and have lost up to 48 pounds, when they only needed to lose 10 to 14 pounds, or five percent.
We focus on lifestyle changes which work well — patients see results fairly quickly.
DR. BARON: Because we all work together, I can see a patient at the beginning of one month, they’ll see Sherri the next month, and someone else from the other team the next month. And then they see me again. It really feels like an incredible team approach to give the full extent of resources to the patient.
MARIELENA CID: Nurses must get certification as a lifestyle coach to lead the diabetes prevention program. We submit reports to Medicare every six months to maintain recognition. People can self-refer to the program if they have prediabetes or impaired fasting glucose. We appreciate the referrals from physicians. We send patients back to their physicians to show what, and how, they’re doing, so the physicians can spread the word and motivate other patients.
DR. DE LA CUESTA: I think people have unrealistic expectations about what weight loss should be. What I consider success is a 10 percent weight loss that’s maintained for one year. It is very hard to convince patients that that is in fact success.
MARIELENA CID: That’s why this program is 12 months long, so they have time to change their lifestyle. Medicare now requires they continue for another 12 months for monthly follow-ups to maintain that weight loss. We want them to have a permanent lifestyle change and not a quick diet and sudden weight loss. They would gain the weight back. We want them to make those long-term changes.
In our program, participants are motivated. They don’t want to get diabetes and this is where they can reverse the disease. When it’s prediabetes, you can get your blood sugar back to normal, but you have to make changes and we can help.
DR. THOMAS: How can physicians refer patients to your program?
MARIELENA CID: Physicians may enter a referral for Diabetes Education Services. If they’re not Eisenhower physicians, they can fax over a referral. We contact the patient and see if they qualify to join, either the diabetes self-management program or the Diabetes Prevention Program. And then we get them started.
DR. THOMAS: You mentioned that prediabetes can be reversed. What is the overall success rate in a program for reversing prediabetes?
MARIELENA CID: Many times it’s just a lifestyle change, the weight loss. When they lose the weight they can improve their blood sugar. Their A1C goes down and their numbers go back to normal. That’s when they are delaying or preventing Type 2 diabetes. But if they don’t change anything, within three years they can advance to Type 2 diabetes.
Unfortunately, we are seeing a lot of people with prediabetes who already have neuropathy, or they have diabetic retinopathy. They’re having issues with prediabetes because they have had elevated blood sugar for many years. They don’t even have to have diabetes to get those complications.
???????DR. DE LA CUESTA: I do see a fair amount of patients who present with neuropathy. Often then know they have mild elevations in their fasting blood glucose but don’t realize that this elevation could cause the neuropathy.
MARIELENA CID: That’s why prevention is so important. Type 2 diabetes cannot be reversed, even if someone gets their numbers controlled. They still have diabetes.
DR. BARON: Prediabetes is where TLC — therapeutic lifestyle changes of diet, exercise, and weight loss — have the most meaningful impact in glycemic control.
I don’t like to use the term “reversal of diabetes,” but what we say is “a disease free interval” or you’ve entered a period of time where you are able to control your own blood sugars.
That tells the patient they’ve done something good and meaningful to allow their body to take care of business. But keep in mind, and it’s very important, that this process is still there, simmering beneath the surface. If they fall off the wagon, the blood sugars will rise again.
SHERRI MASON: Dr. Thomas mentioned success rate. With the original study, wasn’t it a 58 percent success rate with lifestyle change?
MARIELENA CID: Yes, and it outperformed metformin. The group that used metformin for prediabetes had a success rate of 31 percent, and the group that made lifestyle changes had a success rate of 58 percent. And for people older than age 60, the success rate was 71 percent.
DR. BARON: At the end of the day we are empowered to take our health into our own hands to a much greater extent. Pharmacology, medical manipulation, is very important, but if we can put our health in our own hands and do the right thing by trying to eat well and exercise as much as possible, we really can keep a lot of these chronic conditions at bay for longer periods of time.
DR. THOMAS: Final thoughts?
DR. BARON: The group and everybody we have here is tremendous. I think our patients may not recognize the bounty of resources we have available. We are very fortunate to be part of this system.
To find an Eisenhower Primary Care Physician, call 760.773.1460. To learn more about Eisenhower’s Diabetes Education Services and its classes and education, visit EisenhowerHealth.org/Diabetes or call 760.773.1403.