1. What is "metabolic syndrome" or "syndrome X"?
2. What is "prediabetes"?
3. How is prediabetes treated?
4. What is "hypoglycemia"?
5. What is "diabetic ketoacidosis"?
6. What are the risk factors for diabetic ketoacidosis?
7. What are the symptoms of diabetic ketoacidosis?
8. What happens when a diabetic doesn't get enough hydration?
Diabetes: Complications And Conditions
What is "metabolic syndrome" or "syndrome X"?
Metabolic syndrome, which has also been called syndrome X or the insulin resistance syndrome, is a syndrome in people which gives them a high risk for heart disease and a risk for going on to get diabetes. It's kind of inseparable from type 2 diabetes, in a way, or prediabetes. But basically, it is people who are at risk for type 2 diabetes who gain weight in their center. Gaining weight in your center leads to a higher blood pressure level, to abnormal lipid or cholesterol levels, and to an increase in insulin resistance, which means increases in insulin levels and eventually, potentially, to diabetes. So, if you have the metabolic syndrome, first and foremost, it means you need to be assessed for your risk for cardiovascular disease, for heart attack or stroke. Then you also need to be assessed for your risk for going on to develop diabetes.
What is "prediabetes"?
Prediabetes means an elevation in blood sugar levels above the normal level, but an elevation that's not really considered to be diabetes yet. So the definition is if the blood sugar level fasting, without eating overnight, is between 100 and 125, then that's considered "prediabetes." The point of this is that it's not that one day you wake up with the disease that is prediabetes, it means that you slowly started and gradually have gotten your blood sugar levels higher, higher, and higher. What you want to do is not only be aware of what your fasting blood sugar levels are, but to track the change over time. So, if you start out with a blood sugar level of 95 when you're 38, and when you're 45 it's 105, and 2 years later it's 110, you're really getting worse.
How is prediabetes treated?
The first thing you need to do in that setting is worry about your risk for heart disease because most people in that setting have the metabolic syndrome that is a risk for heart attack, stroke, caused by central fat. But, they're also having an increase in blood sugar levels and the way to reduce increasing blood sugar levels is weight loss and exercise. Seems simple, but it isn't and people need to lose about seven percent of their body weight. So it's somewhere between ten and twenty pounds and then you need to keep it off. You need to exercise and exercise five days a week, thirty minutes at a time. Then if that doesn't work, there are some medications that can be taken to prevent progression to diabetes. So, prediabetes, like everything else, can be managed. It can't entirely go away, because even if you go back to completely normal, as you get older, you get more resistant to insulin so it can actually come back. So it's one of those things that you need to be aware of to follow to work with lifestyle changes and then potentially medication to treat and hopefully prevent ever from getting heart disease or diabetes.
What is "hypoglycemia"?
Hypoglycaemia means a blood sugar level that's fallen below normal, and for most people, that means below a blood sugar of 7. And as your blood sugar falls from 7 to 5 in a case of hypoglycaemia, most people will feel it; they'll feel weak, shaky, hungry. And as your blood sugar level falls much below 5 in a case of hypoglycaemia, you stop being able to think normally: you become fuzzy, you can't do math in your head if you could do it before, and you just get sort of out of it, until you might fall into a hypoglycaemic coma. But hypoglycaemia simply means that the blood sugar is falling and the brain is not getting the glucose it needs to function normally. And your brain must have glucose to function.
What is "diabetic ketoacidosis"?
Diabetic ketoacidosis is a very serious complication that happens only in people with type one diabetes. What diabetic ketoacidosis means is that the body has so little insulin in it that it starts to break down fat. It turns out we need insulin to keep fat in our cells as well as glucose in our cells and when the fat breaks down, it causes a build-up of acid, and that build-up of acid can very quickly cause people to become comatose, they become really hypotensive and their blood pressure falls. It's very serious but also very easy to treat, you just give somebody fluid and insulin, generally by vein, until they get better. You could die from it if you have underlying heart disease, if you're elderly or if somebody doesn't treat you soon enough, because in a day or two in this state, you would be dead. So it's a very serious problem, but very very rare.
What are the risk factors for diabetic ketoacidosis?
It happens in people for a variety of reasons. One, if you don't know you have diabetes, you can develop diabetic ketoacidosis because you don't know to get insulin because nobody told you. The second reason is because you get an infection. So, let's say you get pneumonia and your body becomes very resistant to insulin as bodies tend to and you don't get enough extra insulin to compensate. Then you can go into ketoacidosis. The third reason -- and one of the reasons I see this in my population in East Los Angeles -- is because they run out of insulin: they don't have a refill; they can't find a doctor. If you don't take your insulin, this can happen. So, people with Type I diabetes must take their insulin and they must have access to insulin. Otherwise, they can get ketoacidosis; and, in the worst case scenario, they would die.
What are the symptoms of diabetic ketoacidosis?
Symptoms of diabetic ketoacidosis generally start with a person feeling just generally sick. They often get a very severe headache. They get a lot of abdominal pain. They start vomiting, nauseated. They pee a lot in the beginning, but as they get dehydrated, they stop peeing a lot. And very quickly, they'll get very dehydrated and can become comatose. But the headache and the abdominal pain and the inability to keep down fluid is very classic, and those people need to immediately go to seek medical attention, because they can quickly get worse. Those are the most common symptoms.The others are more subtle. People get a kind of breathing pattern, a Kussmaul respiration, where they have the deep breathe in and out, in order to try to get the acid out of their body. And I have had some patients call me on the phone, and I can tell they're Kussmaul breathing and I know they have ketoacidosis. But it's not exactly a way that you want to diagnose it. You basically want to take anyone with type 1 diabetes who's vomiting and unable to keep fluids down and get them to an emergency room.
What happens when a diabetic doesn't get enough hydration?
Hyperosmolar nonketotic syndrome is a syndrome that happens in adults generally with diabetes where they don't actually have enough access to water. Unlike diabetic ketoacidosis, which happens in people with type 1 diabetes where they're very suddenly sick, adults that get hyperosmolar nonketotic syndrome get gradually sick; say over a week, and I often see it in people, say for example they're in a nursing home and can't get to enough water. They're sort of out of it, and their blood sugars instead of being the normal 100 go to 200 and then 400 and then 600 and then to 1000. These are very, very, very sick people, and often they've had a heart attack or they have an infection and it often kills them. On the other hand, they're very simple to treat in a way; they really just need gentle hydration, and a little bit of insulin and they'll come back down to normal. I have seen younger people with this; just the other day I saw a 45 year-old with hyperosmolar nonketotic syndrome who was admitted to a hospital. He hadn't really taken care of or noticed his symptoms over a week and got very sick, came to my clinic after being discharged from the hospital and is now doing fine. So, hyperosmolar nonketotic syndrome is really a state of the body just becoming extremely dehydrated due to high blood sugar levels, but because it happens in elderly people who are also sick for other reasons it can be very serious.
Questions Discussed
1. What is "gestational diabetes"?
2. What are the risk factors for developing gestational diabetes?
3. How is gestational diabetes treated?
4. Can gestational diabetes be prevented?
5. Does gestational diabetes always go away after the pregnancy?
6. If I have gestational diabetes, will my baby be affected?
Gestational Diabetes
What is "gestational diabetes"?
Gestational diabetes is diabetes that happens during pregnancy. Gestational diabetes generally happens during the last third of pregnancy. The reason why it happens is that the placenta that grows around the baby makes hormones that make the mum insulin-resistant. If you think about it, it's a good thing, because what the mum's trying to do is give sugar to the baby because the baby needs to grow and develop. So, what the placenta does is to make sure mum makes plenty of sugar. In someone who's not at risk for gestational diabetes, someone who doesn't get it, their own pancreas makes enough insulin to keep the blood sugar levels normal. However, you could be somebody who's prone to get gestational diabetes, and the risk factors are very similar to those of somebody with type 2 diabetes (if you have a family history, if you're overweight); all of those risk factors make a woman less likely to be able to make enough insulin during her pregnancy. When that happens the blood sugar levels go up because of the insulin resistance caused by the placenta. A woman with gestational diabetes is treated just like anybody with diabetes; through diet and exercise. However, there's not a lot of diet and exercise you can often do in a pregnancy, so what happens is they end up going on insulin briefly until the end of their pregnancy to make sure their sugar levels are normal.
What are the risk factors for developing gestational diabetes?
Not everybody is at the same risk for getting gestational diabetes. If you're in a high risk group, you're much more likely to get it, and if you're a high risk group member, then after the baby is delivered you're at risk for getting diabetes subsequently. Just like everything in diabetes, it's lifestyle. So, if you had gestational diabetes, you had the baby and you're able to lose the baby weight, maybe a few extra pounds if you need to, and exercise, you'll markedly reduce your risk not only of getting diabetes in the future but of getting diabetes with a subsequent pregnancy. Gestational diabetes is really type 2 diabetes brought on in higher-risk people by a pregnancy that causes insulin resistance. Almost everybody that gets gestational diabetes has some risk, but sometimes it happens in women that don't seem to have any risk factors. That's one of the reasons we screen almost everybody with a glucose test during pregnancy, because we don't want to risk missing it. So, even though we think it's more likely, we know it's more likely in women with risk factors, some women without risk factors can also get gestational diabetes.
How is gestational diabetes treated?
Gestational diabetes is treated just like ordinary Type 2 diabetes, in the sense that the first thing we do is lifestyle change. We have people see a nutritionist, we have them work with the dietician on what they can do to eat differently, perhaps reduce the carbohydrates, change the composition of their diet, and increase their physical activity. But if that doesn't work, then we go on to using insulin, which is generally a short period of time, just during the last part of the pregnancy, and then once the woman delivers the baby they no longer need to be on insulin.
Can gestational diabetes be prevented?
In some cases gestational diabetes can be prevented in women who are overweight and sedentary. Those women need to be encouraged to lose weight and to increase their activity prior to conception and then to avoid excessive weight gain throughout the pregnancy. There are some women, though, who just seem to get gestational diabetes, and we really can't prevent it which is why we need to screen women for gestational diabetes at 25 weeks into their pregnancy.
Does gestational diabetes always go away after the pregnancy?
Gestational diabetes usually goes away after the pregnancy, but can come back subsequently over the next months to years, particularly if a woman isn't able to keep their weight in a normal range or exercise. The one caveat to that, though, is that there are women who seem like they have gestational diabetes who are actually getting adult onset Type 1 diabetes. They have antibodies to their beta cells. So there is an occasional woman whose gestational diabetes -- which actually has been sort of misdiagnosed, because it's not gestational diabetes at all -- it's really diabetes that's developing and just happened to be picked up during pregnancy. And those women end up either on insulin or oral medications, depending on the kind of diabetes they have. So I see women whose diabetes doesn't go away after pregnancy, but those are the exceptions, not the rule.
If I have gestational diabetes, will my baby be affected?
Babies born to mothers who have gestational diabetes tend to be too big, and if you control the blood sugar levels that doesn't generally happen. But the problem with babies that are too big is that they tend to get stuck when they come out, so they end up having problems with their shoulders, rates of ceasarean sections are higher, and so there's some issues related to the size of the baby. So we want to control the blood sugar levels to keep the baby a normal size so that birth is easier. After delivery, babies of mom's who have had gestational diabetes can have low blood sugar levels and high bilirubin levels, but all of that tends to be monitored in the hospital for a day or two and then the babies are fine. I think another important point though is that babies who are big at birth and babies who are too little at birth are at increased risk themselves for getting diabetes in the future. So we think that there might be hyperstimulation of the pancreas during pregnancy, we're not quite sure. But I think it's a good idea to treat the gestational diabetes and then if that 's done the baby's going to be just fine and there should be no long term problems with the baby.
1. How can I recognize when someone's having low blood sugar levels?
2. How do you assist a person who is having low blood sugar reaction?
3. What do I do if a person with diabetes loses consciousness?
4. What local resources are available for diabetics and their friends and families?
Diabetes Info For Family And Friends
How can I recognize when someone's having low blood sugar levels?
When someone is having a low blood sugar reaction, they generally start off with a higher blood sugar level and fall to a lower blood sugar level. And during that fall, outside observers can often tell that it's happening, and oftentimes better than the patient can. So say it's your husband or your wife, and you know that when they get, or start to get a low blood sugar reaction they act a little bit spacey, or they put the milk in the cupboard, or they just sort of aren't quite right, or they get a little shakey or a little slurred, you can recognize that and ask them to check a blood sugar reaction. Part of the problem with this is of course, is that sometimes one is right, and sometimes one is wrong and if somebody's a little bit irritable and you test their sugar and they just happen to be irritable, then it is a problem. But the point is that people from the outside can often tell.
How do you assist a person who is having low blood sugar reaction?
When someone is having a low blood sugar reaction, there are basically two phases; one in which they're conscious and can eat or drink something and the second in which they become unconscious. If you're with someone who's having a blood sugar reaction and they can still swallow, giving them some juice, for instance, is a very good thing. People have been known to take sugar cubes and to crush them up in water, but you're basically just trying to give them sugar water, so fruit juice, Coke (not Diet Coke) or any of the kinds of sodas that are sugary. Sugary fluids are a good idea. The problem is that once somebody loses consciousness, they can't swallow, and there may be a point in which they're losing consciousness and they'll fight you. You don't actually want to get in the way of somebody who's got a low blood sugar and who's fighting you. Once they've lost consciousness from a low blood sugar reaction, if you have Glucagon, which is an injection, you can give them an injection of Glucagon and they'll wake up. Or, you'll have to call 911 so that paramedics or someone can come, give them glucose, and wake them up. Now, there are some other things that you can do. Sometimes people have been known to be helped if somebody has cake icing, which is a very concentrated form of glucose, or has real maple syrup. I met somebody in Greece who just rubbed honey on the gums of the person having a low blood sugar reaction and they woke up from the sugar being absorbed through the gums, but you've got to be careful doing that because you don't want the person to bite you, so that's a risk. You don't want to pour water down their mouth because they'll aspirate it; they'll swallow it and get it down into their lungs. So, if they can't swallow it themselves, you really need to either know what you're doing or call someone to come help.
What do I do if a person with diabetes loses consciousness?
Well, if someone with diabetes loses consciousness and you think it's from a low blood sugar reaction, you either treat it right away with glucagon if you have glucagon, or you call the paramedics. But the important things that you want to do is to make sure the person isn't going to fall from a height. So you want to put them on the floor so that they're not going to fall off something, and then tilt their head to the side in case they vomit or have a seizure. Then they're not going to aspirate, which means sort of inhale the vomit or the fluid into their lungs. So just keep them safe. And, even if they're having a seizure, it's okay; they're going to get over it. It seems awful, but just make sure they're safe and in a place they won't hurt themselves, and then help will come or you'll be able to help them. So it's staying calm that I think helps a lot.
What local resources are available for diabetics and their friends and families?
Well, there are many local diabetes organizations that are subsets of national organizations, so there's the European Association for the Study of Diabetes, there's the W.H.O, there's the International Diabetes Federation, there's the American Diabetes Association, the Juvenile Diabetes Research Foundation, a lot of different places which have national websites, and then local links. In many places, there's recognition for certain programs, centers of excellence, there's people who are certified diabetes educators, there's all sorts of local programs that people can get hooked into, often your health care provider will know, and if not, you could search on the internet and find the more international organizations to try to get to a more local place. The other possibility is, if there's a university near you, or even a ways away, you could contact their diabetes department and find out what the resources there are, or get local referrals.
Questions discussed.
1. How are children with type 1 diabetes cared for differently than adults?
2. How are children with diabetes type 2 cared for differently than adults?
Diabetes, Children And The Elderly
How are children with type 1 diabetes cared for differently than adults?
Children with diabetes- if they get type 1 diabetes when they're young- are treated a little bit differently than adults because we're afraid that too many low blood sugar reactions will hurt the developing brain. And in adults, we expect most adults with type 1 diabetes to have two to three mild low blood sugar reactions a week. So we know that using insulin to keep blood sugar levels normal means sometimes people will be a little high and sometimes a little low. With kids, we don't want them to be a little low most of the time, so these standards- the hemoglobin A1c, that average blood sugar test- is kept a bit higher in kids. And early on, obviously, the parents give the insulin. But by the age of four or so, lots of kids can give their own insulin, and they wear pumps, and they do all sorts of things just like adults. So I'm more impressed by kids than I thought I'd be because they do pretty darn well and I think the hardest thing about being a kid with diabetes is being an adolescent with diabetes. And that's a really tough age, and anyone who happens to have an adolescent child knows what that's like. And really most kids rebel and their blood sugars go higher and they get through adolescence and they settle down once they get a bit older, so it's always a tough age.
How are children with diabetes type 2 cared for differently than adults?
When children get type 2 diabetes, they are treated similarly to adults with certain differences. First like with adults, they are treated with changes in lifestyle and with improvements in their exercise and hopefully encouraging them to develop patterns that would be healthy for the rest of their lives. But many, many of the drugs that might work in children with type 2 diabetes have not yet been studied in children with diabetes. So a lot of the pills for adults haven't been tested in kids. So kids are actually treated more with drugs like insulin sooner than adults with type 2 might be treated because we just haven't studied those drugs in children. There are big research studies that are ongoing that are looking at how to treat children with type 2 diabetes but it is actually a pretty new phenomena because up until the last 10 years or so we haven't had lots of children with type 2 diabetes buy we are learning. If a kid has type 2 diabetes as well as type 1 I would really recommend sending that individual to someone that is used to treating kids with diabetes. Even though rates are increasing there is still not lots of those children and I think they need specialized care.
1. What questions should I ask my doctor first when I am diagnosed with diabetes?
2. What's the first thing my doctor will do if she suspects I have diabetes?
3. How will diabetes and its treatment impact my loved ones?
4. What do I do if I have nausea or vomiting and I'm a diabetic?
5. Does taking additional insulin correct a high blood sugar level?
6. What is "diabetic neuropathy"?
7. Why does diabetes increase "fatty plaque"?
8. Why is my blood pressure important if I have diabetes?
9. Why is my cholesterol important if I have diabetes?
10. What is a "triglyceride level" and why is it important if I have diabetes?
11. What infections am I prone to if I have diabetes?
12. How could having an infection worsen my glucose control?
13. What is an "insulin reaction" or "hypoglycemia"?
14. What happens when a hypoglycemic reaction gets out of control?
15. What is the life expectancy for people with diabetes?
16. What are the most common causes of death for people with diabetes?
17. Can I drink alcohol if I have diabetes?
18. How do wine and beer affect my blood sugar level?
19. How does smoking raise my risk of complications if I have diabetes?
20. Should I see a general doctor or a specialist if I have diabetes?
Diabetes Patient Basics
What questions should I ask my doctor first when I am diagnosed with diabetes?
I think one of the most important things that someone can learn early is what type of diabetes they have, whether it's type 1 or type 2. The problem is that many physicians aren't going to be able to distinguish between type 1 and type 2 diabetes, particularly not early on. So, if you are someone who has no family history of diabetes, you're lean, you're young and look for all the world like someone with type 1 diabetes, then that's probably what you have. You need to ask your doctor, "Is this type 1 or type 2, and why?" Then you need to ask your doctor about what treatments you're going to have. I think people also need to always ask if they can see a dietician, because when you first get diabetes, you need to see a dietician, and a lot of physicians may not make that referral. So, I think that, from the get-go, knowing what type you have (or if there's going to be some sort of blood test or something done to figure out which type you have), and then helping your treatment mesh with your diet, from the beginning; that will make your life better.
What's the first thing my doctor will do if she suspects I have diabetes?
If your doctor thinks you have diabetes, the very first test should be a fasting blood sugar test, which basically means that they draw your blood after you haven't eaten overnight, for ten to twelve hours. You can have water and they look to see if its elevated. If it's above one hundred, it's abnormal, and if its about one hundred and twenty-six its diabetes.
How will diabetes and its treatment impact my loved ones?
When people get diabetes, they often have family members who've had diabetes and in many cases they've seen family members go blind or go on dialysis or have just horrible deaths and so there's an element of fear in both the patient and also in the family members. I think that like all things, there's all sorts of ways to deal with fear the least productive way to deal with diabetes though, is denial. The best way is to take the family together and say let's deal with this as a unit, let's figure out how to cook food for all of us that's healthier, let's figure out a way that we can all change our exercise patterns. I think often people with diabetes and their families need to see a therapist. They may need to deal with the depression that comes with getting this diagnosis. Many people with diabetes need to take antidepressants for depression. There's a lot that needs to go on with a family and the individual to psychologically accomodate to this, but once people do, it just becomes part of who they are, just like anything else. A normal adjustment to a stressful situation that can end up really happily.
What do I do if I have nausea or vomiting and I'm a diabetic?
When people with diabetes develop nausea and vomiting, it can be actually quite serious because, if you've given insulin or you've taken an oral medication that lowers your blood sugar levels and you can't eat or drink, you can get very dehydrated and your blood sugar levels can fall. So, in many cases, people with the symptoms of nausea and vomiting will need to go to the emergency room. But the caveat is if you can call your health care team, they can advise you what to do. They can teach you about how to take care of your diabetes when you're sick. They can give you medication to stop the vomiting, then you might not have to go to the emergency room. But it's the kind of situation where many people with diabetes need to contact their physician and then get some assistance. We always give our patients sick day rules so they know what to do when they're sick and I try to prepare people but when someone's sick who has diabetes like that I just want them to call me because I want to know so I can help them through it. It's one of those things you don't want to mess around with but you really want to see the person and do what you can to get them better.
Does taking additional insulin correct a high blood sugar level?
Giving insulin is an incredible art because you're trying to be a pancreas; you're trying to be an internal organ and you're giving it externally. So, if your blood sugar is three hundred, which is way too high as you're supposed to be a hundred (a hundred's normal) and you give a dose of, say, four units of insulin (what we call a correction) to bring it down to a hundred, and you check it an hour later and it's still high, what do you do? Well, what you don't want to do at that moment is give more insulin because we call that "insulin stacking". If you give insulin too soon after the last dose, the insulin can build up in your body and cause a low blood sugar reaction. So, we have people wait for several hours in between doses so that then there's not that risk of a low blood sugar. One of the things that a pump, an insulin pump does, is it actually calculates what we call "insulin on board". So, say you wait for two hours, you check again and you're still high, it will calculate how much of the last dose is still in your body and let you give a little bit more so you come to the right balance. Technology helps us answer that question better, but the rule of thumb is don't give insulin more often than every three to four hours so you don't stack the insulin and cause a low blood sugar reaction.
What is "diabetic neuropathy"?
Diabetic neuropathy means that the nerves are damaged due to high blood sugar levels and it takes on a whole bunch of different forms. The most classic kind is what we call peripheral neuropathy, which is a kind of neuropathy that starts in the tip of the toes. Actually it is on both sides, not just one. It often starts out as a tingling as if the nerves are being irritated. That tingling can eventually become really very bad pain and then eventually that pain goes away and the foot becomes (or both feet) become numb. When those feet become numb it means they can't feel either say a rock or a piece of glass in the bottom of the foot. People often become unsteady because they can't feel where their feet are; they lose what we call peripheral perception or the ability to know where your body parts are in space and that neuropathy can go up your legs you can also get it of your fingers and arms. But the neuropathy for diabetes is not just of those peripheral nerves it is many other places as well. it can affect the nerves that go to the stomach so people get something called gastroparesis which means their stomach doesn't empty normally so they get full and bloated and nauseated. It can cause the bladder to not also empty normally so people can get bladder problems. It can cause the intestines to get too much bacteria so people get constipation and diarrhea. It can cause the sexual organs not to work right so it causes a lot of erectile dysfunction in men and probably causes difficulties in women as well.There is effects on blood pressure as well. It can cause blood pressure to fall abnormally low as well as be too high. And so basically everything in the body that is controlled by nerves, which is pretty much everything in the body, can be affected by diabetic neuropathy. It sounds grim, which it is except that A) we can prevent it and B) if you know that you are at risk for it and we diagnose it then we can offer specific treatments say, for gastroparesis or the bladder problems so like everything, knowing more about it is helpful.
Why does diabetes increase "fatty plaque"?
Diabetes causes a two- to-fourfold increase in the risk of heart disease and stroke. And the reason it does this probably has many different causes. One is because diabetes can cause high blood pressure. But also, inside the artery there's all of these sort of cells and markers and cholesterol. Blood sugar is sort of like taking a smooth surface, say, Teflon, and making it like Velcro. And so blood sugar takes the lining of the arteries and makes them stickier, and it also makes the little particles, the inflammatory cells, the cholesterol, stickier. So when you have diabetes, that sugar level in your blood makes all of the particles that lead to clogging of the arteries just stick more. And that increased stickiness is why people with diabetes have higher rates of heart disease. It's even more complicated than that, though, because people with Type 2 diabetes have other abnormalities. Their liver makes embolic cholesterol particles, their blood pressure's higher, there are a lot of other problems in Type 2 that makes them an even higher risk. But sugar itself I think is taking the lining of the arteries from Teflon to Velcro so stuff sticks to it, and the stuff that sticks to it causes the plaque that leads to heart attack and stroke.
Why is my blood pressure important if I have diabetes?
Blood pressure control is incredibly important for people with diabetes, for a variety of reasons. First of all, people with type 2 diabetes tend to have hypertension. Patients with type 1 diabetes may not have hypertension, but if their blood sugar goes up, it needs to also be treated. The reason for treating blood pressure is as follows. People with diabetes tend to get heart disease at much higher rates than people who don't, and treating hypertension lowers risks of heart disease. In people with diabetes, treating high blood pressure helps prevent blindness because it lowers the pressure on the back of the eyes. It helps prevent kidney disease, particularly if people have some kidney damage. As a result, hypertension treatment is just vitally important. We actually have lower standards regarding blood pressure in diabetes patients. We say the blood pressure should be less than 130/80 in patients with diabetes, which is a different treatment target than people without, because we really think that having a normal blood pressure can make a big difference. Also really, just in terms of overall health, I think it's an important thing to do.
Why is my cholesterol important if I have diabetes?
Treating lipid, or cholesterol levels in diabetes is very important, because people with diabetes have very high rates of heart disease and stroke. And it's not so much that bad cholesterol levels are high in people with diabetes, it's the good cholesterol, or HDL levels are too low, and triglyciride levels, which are a measure of fat in the blood, are too high. But it's not the triglyciride levels that hurt you. It's really the fact that the good cholesterol is too low, and the bad cholesterol, or LDL cholesterol, may be a little bit high. But what it is, is abnormal. Those cholesterol particles are stickier, because of the presence of high blood sugar levels. And so people with Type 2 diabetes and Type 1, but mostly Type 2, have this very accelerated rate of heart disease. So we say, people with Type 2 diabetes, and include Type 1's in this too, 'cause we think it's also important, really need to have their cholesterol, their bad cholesterol, treated to be less than a hundred. And I really want people to know their LDL cholesterol. A lot of people know total, but I don't care about total. Total is the sum of the bad and the good. If your bad isn't very high and your good is too low, your total could be artificially low. So people need to know what is their LDL or bad cholesterol level, and it needs to be treated to less than a hundred. And if people have had heart disease already, it should be treated to less than seventy. So treatment of cholesterol levels is very important, and is actually different than in patients without diabetes.
What is a "triglyceride level" and why is it important if I have diabetes?
A triglyceride level is a marker for abnormal cholesterol particles. If your triglyceride level is high, it means that the pathway through which you metabolise your bad cholesterol levels is not normal, so it means your bad cholesterol is stickier than in someone without diabetes. So, a triglyceride level that's elevated is a marker for an increased risk for heart disease and building up plaque in the arteries, but in itself isn't going to hurt you; it's what it means in terms of the entire set of features for heart disease risk in diabetes.
What infections am I prone to if I have diabetes?
In my experience people with diabetes whose blood sugars are controlled don't tend to get infections at any higher rate then anyone else, but if blood sugar levels are high even a little bit, there are a variety of different kinds of infections that can occur. Common infections I see, especially in women, are urinary tract infections and yeast infections. I can almost tell a young woman's blood sugar levels by how often they're having yeast infections. I think yeast like that sugary stuff that grows down there when blood sugar levels are high. The same thing goes for other kinds of fungus; foot fungus (the thickening of the nails) is really common in people with diabetes. I think fungus likes sugar. In people whose blood sugar levels are high there are important infections that they can get, for instance, sometimes what seems like a little tiny infection of the skin can end up going down to the bone, and become what we call osteomyelitis, or an infection of the bone. People with diabetes can get other infections, of say their sinuses or their ears; sort of rare uncommon infections. The vast majority of those people have very poorly controlled diabetes. In most cases good control of diabetes helps control the effect of the high risks of infection.
How could having an infection worsen my glucose control?
When people with diabetes, either type 1 or type 2, develop an infection, they get what we call 'Insulin resistance'. 'Insulin resistance' means that the body doesn't respond as well as it should to circulating insulin levels. So, say somebody with type 1 diabetes gets a head cold. Their blood sugar levels which may normally be a hundred may suddenly become 200 even though they have the same dose of insulin, so they are resistant. An infection makes you resistant to whatever your usual treatment is. As a result, many of my patients can tell when they are getting sick, because their sugar levels go up. Then, as long as they are sick, their sugar levels will stay high, and then they'll come down back to normal once the infection clears. In patients who aren't on insulin as often, I have to increase their insulin doses in order to bring their blood sugar levels back down. It's something that happens in all of us, but we, those without diabetes who get infections, don't know that we need to make more insulin, because our pancreases do it without thinking about it. However, in diabetes we just need to increase the medication to do with it.
What is an "insulin reaction" or "hypoglycemia"?
An insulin reaction, which is also called hypoglycaemia, basically means that your body has too much insulin, so too much sugar goes into the cells, and then the blood sugar to your brain starts to fall. Now, all of us have had a hypoglycaemic reaction; say you eat a doughnut and then two hours later you're trying to focus but you just feel all shaky and jittery and you've got to eat; that's a blood sugar reaction. That means that your blood sugar levels are falling. Your blood sugar level may not get too low, but your sugar level is falling and you feel it. We call that the adrenergic signs of a low blood sugar reaction; you feel shaky, sweaty, hungry, weak, tremulous, all of that happens. If you eat something, if you eat sugar right then, your blood sugar level will come back up to normal and you're fine.
What happens when a hypoglycemic reaction gets out of control?
The problem is is in diabetes sometimes the insulin dose is so much that you don't have time to treat it or what happens is you're not carrying sugar with you, which people with diabetes all should do. Or, in people who have had diabetes for long enough they lose warning signs like that, and so what happens is the blood sugar level keeps getting lower and lower and lower, so instead of being a hundred, it becomes seventy, then it becomes fifty. And below fifty people tend to lose the ability to think and see normally, and eventually they'll lose consciousness, and that's what we call a sever blood sugar reaction, it's when you are, lost consciousness and someone else has to revive you, they either have to call the paramedics or give you an injection of something called Glucagon, and those are really awful reaction for the people who have them. We try really hard adjust the insulin, to do what we can to prevent those reactions, but they still do occur. So when those happen, if someone's prepared and has Glucagon that can be given, sometimes patients will have seizures at that point, not everybody but some people will, and like all seizures they tend to pass, but again, the paramedics generally come, patients are treated and then they'll get better. So they're disturbing events and everybody who's on insulin or anything that can cause their blood sugars to go too low, some of the oral agents should carry fast acting sugar with them, say Glucose tablets or Glucose gel or little cartons of juice, or whatever they need to bring their blood sugar back up so they don't get those severe reactions.
What is the life expectancy for people with diabetes?
The life expectancy for people with diabetes used to be significantly reduced. And, in fact, life expectancy is reduced by a lot. If you get diabetes at the age of 18, I believe your life expectancy is reduced by 16 to 17 years. If you get it when your 40, it's reduced by about 14 years. That's a lot of years. On the other hand, if you get diabetes and you take care of it your life expectancy isn't reduced at all, neither with type one or type two. You have the same life expectancy. So my mission is to be sure everybody gets good care for their diabetes, and even though what I do for a living may not be all that dramatic, what I'm doing is giving people back years and I think that's wonderful, so this is a treatable disease and life expectancy can just be the same as everybody else, but people have to get treatment.
What are the most common causes of death for people with diabetes?
By far and away, the most common cause of death in people with diabetes is cardiovascular disease, heart attack and stroke. That's what people with diabetes die from. We end up seeing many of our patients with diabetes either diagnosed just at the time they had their bypass surgery or not that long after. So it is very important to work with people with diabetes to prevent their risk for heart attack and stroke equally as important, if not perhaps more so, to lowering their blood sugars.
Can I drink alcohol if I have diabetes?
Many people, when they get diabetes, are afraid that they can't drink alcohol anymore. Actually, that's not true. There are lots and lots of studies that show that moderate consumption of alcohol, both in people with and without diabetes, actually helps prolong life and lower the risk of cardiovascular disease. So it's good for you: it relaxes you, it may have antioxidant benefits, who knows? If you don't drink alcohol, I don't think it's a good habit to start. But if you do, you can do it safely. You do have to know a thing or two, however, because drinking alcohol lowers blood sugar levels. Most people don't understand this, and I've actually had some patients get into real trouble who go out after work, they're not used to drinking, they drink a couple of margaritas and their blood sugars go way too low. But it turns out that alcohol inhibits the liver's production of glucose. So when people with diabetes drink, they need to make sure they eat something, eat some carbohydrate to balance out the alcohol. They also may need to give less insulin or take less medicine. This is definitely something to discuss with one's health care provider.
How do wine and beer affect my blood sugar level?
Many people think wine has lots of carbohydrate in it, and it doesn't. It's got sugar alcohol, which doesn't raise blood sugar levels, so a glass of wine can lower your blood sugar levels. But beer, which is made from corn, has lots of carbohydrates in it, so increases blood sugar levels. And so, many times, switching from beer to wine, or from beer to low-carbohydrate beer, actually will lower blood sugar levels and help balance the diabetes. So alcohol, like anything, can actually be added into the diabetic lifestyle, but it needs to be done knowing the effects of the alcohol and how to prevent low blood sugar reactions.
How does smoking raise my risk of complications if I have diabetes?
Smoking is really, really bad for you if you have diabetes or even prediabetes because what it does is, it makes insulin resistance worse. It increases your bodies reaction it makes your body less reactive to insulin and it also causes constriction of things like the coronary artery, so it makes the risk for heart disease worse. It makes the blood surgers higher so in addition to the risk of cancer smoking actually markedly both worsens insulin resistance and coronary heart disease which is the primary reason people with diabetes die. Smoking is just not something to do if you have diabetes. It also can affect the blood flow to the feet and legs and diabetes can affect that as well and smoking makes that worse. It's just people don't usually realize the effect of smoking and diabetes but it's bad and people really should try whatever they can to stop smoking.
Should I see a general doctor or a specialist if I have diabetes?
Ninety-five percent of people with diabetes in the United States see a general doctor for treating their disease, and I think that it's going to stay that way because there aren't enough of us endocrinologists, and we're not exactly a field that's increasing. I think it's really important to find a good general doctor who will answer your questions and work with you. Unlike most diseases, diabetes is numeric, so you can keep track of your A1Cs, your blood pressure, your LDL cholesterol level. Take charge, bring your data to the doctor, really work with your physician to get yourself down to where you need to be, and make appointments that aren't urgent appointments. Don't just go because you're sick, go because you want to deal with the diabetes, and I think that most general doctors can manage diabetes just fine as long as you're proactive and put something of yourself into managing the disease. My caveat, though, is that if you have Type 1 diabetes or really-difficult-to-control Type 2 diabetes, that's when you may need to see a specialist. I see lots and lots of people with Type 1 diabetes because I think they need to see me - I'm adjusting their insulin, putting them on pumps, doing all sorts of things that I think requires a specialist for care. I think in that case you may want to go to a local center that's got some expertise in diabetes, but most people with Type 2 diabetes can be treated with their primary care provider.
1. What are risk factors for developing diabetes?
2. Is it possible to prevent type 1 diabetes?
3. Is it possible to prevent type 2 diabetes?
4. Is it possible to prevent the complications of diabetes?
5. How do I know what an appropriate meal size is if I have diabetes?
6. How should I care for my skin if I have diabetes?
7. How should I care for my teeth and gums if I have diabetes?
8. Why is type 1 diabetes considered an autoimmune disease?
9. What is an "autoimmune disease"?
10. What environmental factors contribute to diabetes?
11. Why are people getting type 2 diabetes at a younger age?
12. Is diabetes just a problem in the USA and other "Western" nations?
Diabetes Prevention
What are risk factors for developing diabetes?
There are many risk factors for developing diabetes. First is age, so as people their risk for type 2 diabetes goes up and so being older than 45 years is considered a risk factor for diabetes. Being overweight is a very strong risk factor for diabetes particularly weight in the center. So people who gain weight in their center are those who are at highest risk. Having a family member with diabetes puts you at increased risk. There are certain ethnic groups such as native americans, african americans, latino americans, pacific islanders and asian individuals who are at higher risk for developing type 2 diabetes. People with high blood pressure are at higher risk for type 2 diabetes. People who have abnormal cholestorol levels are at higher risk for type 2 diabetes. Women who've had a big baby, meaning a baby that weighs more than 9lbs are at increased risk for having diabetes. Also, for women who've had gestational diabetes. Having polycystic ovarian syndrome, which is a syndrome people have infrequent or irregular menstrual cycles and developing facial hair and other findings are also associated with and increased risk for diabetes. So there's a whole list. Many things that many people have that put them at higher risk for getting type 2 diabetes. But, I would say the two most common findings that I see again and again are people who have a family history of diabetes and people who are gaining weight in there center. Now, in addition to a family history of diabetes, a family history of heart disease also puts you at much higher risk because before you actually get problems related to blood sugar levels, you may have problems related to high blood pressure and abnormal cholestorol. So, often people will have a heart attack first and then get their diabetes later. So I actually look at alot of heart disease as somewhere on the spectrum of getting diabetes.
Is it possible to prevent type 1 diabetes?
Type 1 diabetes, as far as we know, is not yet preventable. But there's a lot of research that's ongoing to try to find the genetics of type 1 diabetes, and also to try to find ways to prevent it. So it's something that's on the horizon, but unfortunately we have no way to prevent it at present.
Is it possible to prevent type 2 diabetes?
Type 2 diabetes is really preventable. The first thing you have to do is know you're at risk. And really try to figure out not only if you're at risk, but if the people in your family are at risk. The real way to prevent type 2 diabetes sounds simple but it isn't. It means you need to lose weight if you're overweight and exercise. Now, it doesn't mean that you need to become thin. If you need to lose a hundred pounds, you don't have to do that to prevent diabetes. You only really have to lose about fifteen pounds, about seven percent of your body weight. So for a lot of people, that's twelve to twenty pounds. If you lose that weight, and if you keep it off; it will prevent diabetes. Now, in addition you need to exercise, and I don't mean running marathons although that might not be bad. What you really want to do is to exercise for thirty minutes a day, five days a week and we think that walking, for instance, is a very good way of getting exercise. Also, just gently going out, just moving your body, increasing your exercise, and if you can over time increasing the intensity this is perfect. But getting exercise and losing weight prevents diabetes. For a lot of people, that's really hard to do. And everyone's busy and people don't have the time to do it and the really important part is that people don't have the time to maintain it. So a lot of people can lose twenty pounds but keeping that twenty pounds off is the hard part. So a lot of individuals will develop diabetes gradually and there's now ways we can try to use different medications that are actually meant for treating diabetes but if we use them earlier we can prevent diabetes. But my key message is lifestyle. So if you have an overweight fifteen year old and you or someone in your family has type 2 diabetes, the best thing you can do for that kid is to really work with them in terms of helping them choose healthy lunches, giving them breakfast, getting them to do physical activity, making habits young that will last for a lifetime and that's how you prevent diabetes.
Is it possible to prevent the complications of diabetes?
I think that the most of the complications of diabetes are preventable. Unfortunately they are not reversible so if somebody doesn't know that they have diabetes for 10 years they can come to me with the nuances of diabetes onset only they just found out and they already have damage to their eyes, their kidney and their nerves. So first and foremost people need to get diagnosed early. They need to find out what their blood sugars are, they need to see if they are at risk and then if you put people like that under good care and they keep coming back and getting good care, in my experience they really don't get diabetic complications. Now, there may be a little problem here and there, there may be a little damage to the eyes, little damage to the kidneys over 20 – 30 years but in general it's not something the person really notices and if it's treated then you can really deal with that.
How do I know what an appropriate meal size is if I have diabetes?
First of all, I think that everybody with diabetes should see a nutritionist, a dietician, or somebody that works at a program, or at least read books about nutrition – because people really need to eat in a way that's healthy. A very important way to eat, and a healthy way, is to reduce portion size. And, people need to get a sense of what normal portions are. And, I think that the best way to do that is to use your hand. So, everybody should take their hand and look at their palm. And, so – guys get a slightly bigger size than a woman does. But, if you look at the palm of your hand, and trace around it, that's about the amount of protein that you should eat a meal. And, in fact, it may be the amount of protein you need in a day. And, that's about the size of a deck of cards. And, you want to look at the width of the meat or protein as being about the width of your thumb. So, if you think about what you could eat if you went out for some gigantic steak, it's going to be twice as big and much thicker. That's way too much protein, and in fact, something you may want to split with someone else because when you eat that much protein, you generally get a lot of fat, and that, together, is not so good for you. Now, your hand is also useful for a variety of other things. You want to, for instance, figure out how much is a cup of something, or a half a cup of something, so a portion size of rice is a third of a cup – that's very little, that's only about half or a third of your palm. Your palm cupped is about a cup's worth of something. So, if you want to eat a portion of mashed potatoes or cereal, it's probably going to be about the amount that fits in your palm. So, again, it's not very big compared to what we're usually used to eating. And, then, if you're going to do a tablespoon, of, say, salad dressing, a tablespoon is about the amount of the tip of your thumb. So, you want to start getting a sense of your own portions and reducing portion size.
How should I care for my skin if I have diabetes?
People with diabetes when their sugars are high, often get dry skin and they may get even itchy skin which responds best, I think, to controlling the blood sugar levels. Otherwise, people with diabetes just deal with their skin the way that anybody would in terms of lotions and creams and trying to deal with the dryness externally. But, if you can control the blood sugars, I think that's the best way to treat it overall, and if you got a cut or sore, any kind of infection on your feet, that would mean you need to contact your doctor. That would not mean something you can treat yourself but rather to contact your health provider for and get some advice about what to do next.
How should I care for my teeth and gums if I have diabetes?
People with diabetes get more gum infections and more cavities than people without diabetes, but like everything in diabetes, it's all related to blood sugar levels, so the more normal the blood sugar levels, the more normal the teeth. So, people with diabetes need to make sure that they go regularly to the dentist, and they may often need to go more often because they're being treated for prior damage that happened when their sugars was higher. But once things get under control and the diabetes is treated, my expectation is that they should do just as well or as poorly as anybody else with their teeth.
Why is type 1 diabetes considered an autoimmune disease?
Type 1 diabetes is an autoimmune disease because it's a disease in which the body makes infection-fighting cells, what we call antibodies, that, by mistake, attack the islet cells, the insulin-producing cells on the pancreas. It is because of that that the body cannot make insulin any further and people get type 1 diabetes.
What is an "autoimmune disease"?
An autoimmune disease means the body makes a mistake. It looks at some normal tissue and says, "That's a foreign invader." So, in the case of diabetes, the body looks at all its cells and says, "There's something wrong here," and tries to kill off the eyelet cells by an autoimmune response, making antibodies. In the case of rheumatoid arthritis the body looks at joint tissue and says, "That's not normal," and the autoimmune response is that the body tries to kill it off. And so an autoimmune disease is really a mistake by the immune system, and that mistake creates a disease.
What environmental factors contribute to diabetes?
There probably are a lot of environmental factors that contribute to causing or triggering Type 1 diabetes but we don't really know what they are. We know that there are certain viruses. There are certain subtypes of Coxsckie viruses, for instance, which we know can cause Type 1 diabetes but most of the time we don't know what caused it. We know something in the environment triggered it, but we really don't have any idea of what that is. Eventually we will figure it out but we don't know yet.
Why are people getting type 2 diabetes at a younger age?
People are getting type 2 diabetes at younger ages because we are basically seeing an epidemic of obesity and inactivity in children. So if you think about it, when you see the classic guy in my clinic who is 45, 50 years old - he's got a central ponch. He has got a family history of type 2 and he comes to see me because he has diabetes. He'll tell me very proudly that he played something in college. That he was thinner than his wife when he got married, that he was fit and he is proud of that. And he will say, "I don't know what happened." But we know what happened, you know the kids, house, the mortgage. But we know that he was fit in high school and college. The problem is, is that his son is a couch potato. His son isn't going out and doing anything more than walking to school even if that. His son is spending hours and hours of time doing things that aren't physically active. So we are shifting. So instead of being 50 and becoming fat, people are becoming 10 and becoming fat and that means that this disease is now starting when they are ten, not fifty, which means this epidemic is going to be seen in fifteen year olds, twenty year olds, thirty year olds. And they're going to get heart disease. They are going to get strokes and they are going to get diabetes before they are forty.
Is diabetes just a problem in the USA and other "Western" nations?
Diabetes is an epidemic that's happening around the world. The two leading countries, in terms of developing diabetes, actually turn out to be India and China. The reason that is, because, they now have an influx of western dollars. Their societies are doing well, people aren't as poor as they once were. The way that I look at this is, maybe, all of those people who survive all of that poverty have these great genes for survival. Those same genes now, when they have food, are causing them to store food in their center and cause them to go on to get diabetes. In fact, in Asian individuals, the amount of fat they have to have, in their center is much, much less than in someone, say, from East Los Angeles where their guts are much bigger. So, very low levels of obesity or being over weight, Asian individuals develop diabetes. I think they are very good at surviving famine but, now their environment has changed. At least for many of them they are not as poor, they have more food, they have more fast food, they have fast food all over the world and people are getting diabetes.
