Diabetes and COVID; physical therapy for cystic fibrosis; avoiding smartphone addiction: Upstate Medical University's HealthLink on Air for Sunday, June 5, 2022
Endocrinologist Roberto Izquierdo, MD, tells how some new cases of diabetes are related to COVID infections and explains general aspects of Type 1 and Type 2 diabetes treatment. Physical therapists Zachary Boswell, DPT, and Connor Delaney, DPT, talk about resourses for people with cystic fibrosis. Psychiatrist Christopher Lucas, MD, gives advice for preventing cellphone addiction.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a pair of physical therapists talk about how they help people with cystic fibrosis.
Zachary Boswell, DPT: ... If you're breathing, and you notice your belly going up and down, that means you're more than likely using your diaphragm. If our shoulders are going up or down, then we are more than likely compensating with other muscles. And that's just not as efficient. ..."
Host Amber Smith: An endocrinologist explains how some new cases of diabetes are linked to COVID infections.
Roberto Izquierdo, MD: ... In our own population here, the patients with newly diagnosed Type 1 diabetes have increased by 30%. In some places, like a report from a hospital in San Diego, it increased by 57%. So that's very alarming. ...
Host Amber Smith: All that, some expert advice about avoiding cellphone addictions and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, a pediatric endocrinologist explains the link between some new cases of diabetes and previous COVID infections. But first, we'll look at how physical therapy can help someone with cystic fibrosis.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Cystic fibrosis is an inherited disorder that can cause severe damage to the lungs and the digestive system and other organs in the body. Today, I'm talking about resources that can be of help to people with this disease. My guests are doctors of physical therapy Connor Delaney and Zachary Boswell, and we're going to start with a little bit of background about cystic fibrosis. Is this a disease that people are born with?
Connor Delaney, DPT: Yes. So this is a disease that is inherited by both of their parents. Typically both the parents do carry a specific gene. They do not have cystic fibrosis. They just carry it, and typically it's unknown if they have that gene or not. But when both parents do have the gene, it can be carried over to the child. And they typically have a one-in-four chance that the child would NOT carry the gene and not have cystic fibrosis, but there is a chance that with both parents being a carrier, that they will have cystic fibrosis.
Host Amber Smith: What problems does cystic fibrosis create in the body?
Connor Delaney, DPT: It typically affects the lungs, and it can also affect the digestive system, where with the thick mucus it can cause the ducts to get plugged, and it will interrupt the ability for them to breathe, be able to digest their food well. That's the most common. It can also affect them to have increased sweat and also to have very salty sweat, which can cause other issues in the body as well.
Host Amber Smith: Are there medications, or is there any cure for this?
Zachary Boswell, DPT: So right now, the current treatment plan involves medications that help control the symptoms, that might fight any infections from the bacteria or viruses that are around us, maybe some steroids to help with inflammation or to help the breathing become a little bit easier, opening up the airways. There are some medications that are talked about that aren't necessarily approved yet by our FDA (Food and Drug Administration) that specifically would work on that same gene that Dr. Delaney was speaking about that could directly have an impact on the symptoms that we see, but that is not readily available, as of yet.
Host Amber Smith: So mostly, if I understand you correctly, Dr. Boswell, mostly the treatments are targeting the symptoms.
Zachary Boswell, DPT: Yes. Thinning that mucus that gets thickened because of the disease process, as well as the inflammation that's caused by that process. And besides the medications, addressing the other impairments that we see, like where the nutrition or with the physical stuff that is secondary to that initial process.
Host Amber Smith: Has the expected lifespan grown for someone with CF during your career as a physical therapist?
Zachary Boswell, DPT: The lifespan has increased significantly, with increased knowledge of what is happening, how to screen and diagnose, particularly any child who's born in the United States is screened for this gene as part of standard care, so it's identified sooner than previously. And treatment has improved, with medications as well as incorporating multiple people in that care, from your lung doctor to the nurses, the nutritionists, the pharmacist for the medications, your physical therapists, respiratory therapists, social worker. We are seeing that have a positive impact on the lifespan.
Host Amber Smith: Well, let's talk about the role of the physical therapist in caring for people with cystic fibrosis. Do primary care providers typically connect their patients who have CF with a physical therapist?
Connor Delaney, DPT: Typically if a cystic fibrosis patient was seeking physical therapy for help for managing their symptoms, they will be referred by their primary care physicians. As for physical therapy with the cystic fibrosis, we do have a lot to offer them that comes along with helping them clear those secretions that are thickened in a couple of different ways. We can do it manually by giving them cupping therapy or percussion therapy to their chest, into their lungs. We also give them -- they can have a device that's called the Flutter and that will help them with positive expiratory pressure, and that's basically just to help elicit a cough, for them to be able to cough up the mucus that is thickened or to help strengthen their muscles, their breathing muscles. We also can help facilitate them to exercise properly and dose their exercise prescriptions of how much they should do, what the intensity should be, and how many days a week they should do it. We can also help with breathing properly, good diaphragmatic breathing, to not use so much of their chest muscles and more of their belly muscles.
Host Amber Smith: Let me ask you a little bit about your patients. What is the youngest patient that you care for that has cystic fibrosis?
Zachary Boswell, DPT: We see patients across their whole lifespan, so as young as newborns to the adolescent or the adult patient who is coming to the clinic or is admitted in the hospital either for maybe a flare-up of the CF that they've been living with, or some other medical condition that warrants coming to the hospital. So it really is a broad range, typically younger, but a broad range of ages.
Host Amber Smith: So once you have a young patient who's coming to see you, that person may stay with you for years?
Zachary Boswell, DPT: Absolutely. And that's one of the reasons why when it comes to working with people who have been diagnosed with cystic fibrosis, we have particularly at Upstate a few therapists who more so specialize with working with people in that population. Because it is such specific care, and to be able to have that professional relationship, it just improves the overall care of that patient.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with a pair of doctors of physical therapy, Connor Delaney and Zachary Boswell, about resources that can help people with cystic fibrosis.
Now, Dr. Delaney, you were talking about airway clearing, and you mentioned some things I wanted to understand better. Cupping therapy and percussion, can you explain what those are?
Connor Delaney, DPT: Yes. So what it is, is typically we use our hands, and we just put them in kind of like a cupped position, and we repeat the movement on the patient's body, to help move around and decrease the thickness of the mucus in their chest, in their lungs, to help them cough it up better. So it's typically done in different positions as well. In order to get a specific lobe of the lung, the lower lobe or the upper lobe, and that helps them just get better clearance.
Host Amber Smith: And what is pulmonary rehabilitation?
Connor Delaney, DPT: Pulmonary rehabilitation is a type of physical therapy where the patient will come and we monitor their vital signs, their heart rate and their oxygen to be able to give them a moderate-intensity exercise, which is where research shows is the most beneficial to the patient to see improvements.
Host Amber Smith: I was going to ask, is there a particular way of breathing? Do you coach people with cystic fibrosis to breathe a certain way that's helpful?
Zachary Boswell, DPT: Yes. And Dr. Delaney mentioned a word earlier, the diaphragmatic breathing. So we can use a lot of different muscles to breathe. Some are more efficient or use less energy than others. So our diaphragm is our main breathing muscle that when it contracts, it helps pull our lungs open more effectively than others, such as muscles in our neck or in our chest, where are useful. If you're exercising or breathing fast or hard if you need to. However, they use a lot of energy, and they don't move air as effectively. So we encourage patients to use that diaphragm. And ways we can check on that is if you're breathing and you notice your belly going up and down, that means you're more than likely using your diaphragm. If our shoulders are going up or down, then we are more than likely compensating with other muscles. And that's just not as efficient or ideal.
So using those cues to feedback or having the patient place their hands on their belly, encouraging a controlled breath in and a nice breath out, nose out through the mouth. That is one of the main ways that we can instruct and improve our breathing techniques.
Host Amber Smith: Does that make exercise difficult for someone with cystic fibrosis?
Zachary Boswell, DPT: Absolutely. Our heart and our lungs work very closely together. The heart needs oxygen, and our lungs need the blood flow in order to carry that oxygen. So if our breathing, that one part of that system isn't working as effectively or efficiently, it's going to make any exertion more challenging. We may experience fatigue or getting tired sooner than others. Our heart rate might go higher. Our oxygen numbers may suffer a little bit or a respiratory rate, how fast we're breathing, goes up. So that's one of the reasons why for pulmonary rehabilitation it's important to have providers who are knowledgeable in that area to monitor for those signs and symptoms to make sure we're doing enough to be beneficial, but not so much that we may be crossing that threshold of being unsafe.
Host Amber Smith: Is it true that people with cystic fibrosis are at higher risk for developing osteoporosis, where their bones become more brittle?
Zachary Boswell, DPT: It is. And that is a result of poor absorption of nutrients in our GI (gastrointestinal) tract. Our bone health is significantly affected by our intake of vitamin D, which we can create through sun exposure, but also through our nutrition, and also calcium. So another nutrient that our bone is made up of primarily. And if we aren't absorbing those nutrients effectively, our body doesn't have the necessary materials to maintain that health. And it can be to the detriment of our bone health.
Host Amber Smith: So nutrition, it sounds like, is especially important for someone with CF, to help maybe. Would that help reduce the risk of osteoporosis?
Zachary Boswell, DPT: It can. It can mitigate the risk, or it can also manage the risk. So it may not remove it completely, but with the assistance of a registered dietician nutritionist, or that individual person, we can find strategies to provide the source on the route of nutrition that would be most appropriate in that situation.
Host Amber Smith: Are people with cystic fibrosis more prone to dehydration?
Connor Delaney, DPT: Yes, they are more prone to dehydration typically because of the increased sweat glands that it affects and that their sweat is more salty. So it does dehydrate them more than a person without a cystic fibrosis.
Host Amber Smith: So typically doctors will tell people, you know, to drink more water. Is that safe advice for someone with cystic fibrosis?
Connor Delaney, DPT: Yes. Drinking the adequate amount of water is important, which is something they would also talk to their registered dietician about. They will help them make sure that they get the appropriate amount of water, along with their nutrition plan, which will also help. If they're on the right nutrition plan, that will help them get as much water as they need as well, through certain foods as well.
Host Amber Smith: Now, are there some physical things that people can do to reduce joint and muscle pain? Dr. Boswell?
Zachary Boswell, DPT: Absolutely. One of my favorite sayings is "motion is lotion." And we know from physics that an object in motion stays in motion. Our bodies were made to move, but we want to be careful about how we're moving. So activities such as walking, some folks enjoy dancing, cycling, either on a bicycle or on a stationary bike, swimming is excellent. And then in the appropriate situation, once you've talked to your physician and been cleared to do so, some strength and resistance training is also beneficial to help with that muscle strength, increasing that bone health, and then focusing on flexibility. So things like yoga or stretching, doing those breathing activities to keep the muscles in our chest, in our lungs and our abdomen limber. All of those will contribute to a very healthy activity and a healthy lifestyle.
Host Amber Smith: Before we wrap up, let me ask what sort of resources or supports are available in Central New York for people with cystic fibrosis.
Connor Delaney, DPT: There is a chapter of the Cystic Fibrosis Foundation right here in Syracuse, New York, right in downtown. They have a website that you can reach that has their location, their address, as well as a phone number and email to email a person to get any information on how to live a life with cystic fibrosis, how to management education and support groups.
Host Amber Smith: Very good. So how would someone connect with a physical therapist who specializes in cystic fibrosis?
Zachary Boswell, DPT: Any new patients would require a physician referral. So if there are any questions or interest in an appointment, you can speak with your primary care provider, or if you have a pulmonologist, for example, and they can write a referral for physical therapy evaluation and treatment, and they can specify if there is a specific diagnosis, such as cystic fibrosis. That way it can be reallocated to the appropriate therapist who might be able to help best. That information is available on Upstate.edu. Just search "physical therapy."
Host Amber Smith: Well, I appreciate both of you making time for this interview.
Zachary Boswell, DPT: Yes, ma'am, and thank you.
Host Amber Smith: My guests have been Zachary Boswell and Connor Delaney. They're both doctors of physical therapy at Upstate. I'm Amber Smith for Upstate's HealthLink on Air.
How COVID is connected to Type 1 diabetes -- next, on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." During the pandemic in 2020 and 2021 doctors saw a significant rise in the number of people, especially children, diagnosed with Type 1 diabetes, and now it looks like kids under age 18 are more likely to receive a new diabetes diagnosis within 30 days of a COVID-19 infection than their peers who were not infected. Here to talk about the reasons for that is Dr. Roberto Izquierdo. He's a professor of medicine and of pediatrics at Upstate and also the chief of pediatric endocrine and diabetes. Welcome back to "HealthLink on Air," Dr. Izquierdo.
Roberto Izquierdo, MD: Well, thank you for having me. Good morning.
Host Amber Smith: You and your colleagues from six other hospitals looked back at your data about new patients with Type 1 diabetes from 2019, before the pandemic, and 2020, during the pandemic. What did you find?
Roberto Izquierdo, MD: Well, we found that there was an increase in the number of children with Type 1 diabetes that were newly diagnosed with the condition. We also found that there was also an increased proportion of those children that presented with diabetic ketoacidosis, which is a life-threatening complication of Type 1 diabetes in which your blood sugars reach a very high level, and you also start to see the appearance of these chemicals called ketones. Ketones are produced when there's not enough insulin, and as you know, Type 1 diabetes is an autoimmune condition, or disease, in which,the cells that produce insulin in the pancreas are destroyed or damaged, and they cannot produce insulin.
So this lack of insulin does not allow the sugars in the blood to enter the cells because insulin acts like a key that opens the door for sugar in the blood to enter the cells to be converted into energy.
So somehow the body has to try to get around this, and it starts burning fat, and part of fat metabolism is the production of these ketones, which are, in small amounts, very useful; they're helpful when you're fasting, for example, because they could be utilized by the heart, the brain, as energy, as an alternative fuel.
But without insulin, that process is not regulated, and the ketones accumulate in the blood drop the pH in the blood, and then that makes you acidic. And that could lead to all sorts of problems, like lethargy, coma, nausea, vomiting, abdominal pain.
So if you're seeing children who have diabetic ketoacidosis when they're diagnosed, does that indicate that it's a more advanced form of Type 1 diabetes or that they've had a more severe case?Well, I would classify it as a more severe presentation because we also see patients that are early on in their diagnosis, that are referred, and those patients are not admitted to the hospital and we could treat as an outpatient.
Host Amber Smith: I see. Now help us understand, because in recent years we've heard about a surge in the numbers of people being diagnosed with Type 2 diabetes, but that's entirely different from Type 1. Is that right?
Roberto Izquierdo, MD: That's correct. Yeah. Type 2 diabetes is another form of diabetes, in which the body is able to produce insulin, but the tissues, like the muscle cells, for example, are not responsive to the insulin. So we call that insulin resistance; the cells in the pancreas, the beta cells, have to produce more insulin to keep up with that insulin resistance.
But when it cannot keep up with that amount of insulin resistance, then you develop Type 2 diabetes. Now Type 2 diabetes is highly familial, so if your brother or sister or parent have Type 2 diabetes, then you are at increased risk for Type 2 diabetes also -- significant. So it's genetics, but also the environment, so eating high-fat foods, sedentary lifestyle, weight gain can increase your risk of developing Type 2 diabetes.
There's reports also of an increase in incidents of Type 2 diabetes during the pandemic. Because many of us were more sedentary, less active, eating more at home, and that led to weight gain, and we've seen an upsurge, too, of Type 2 diabetes.
Host Amber Smith: I see. So in Type 2, the pancreas might still be functioning or making insulin, but in the patients that you're seeing with the Type 1 diabetes who are recovering from COVID, their pancreas is not producing insulin anymore. Is that right?
Roberto Izquierdo, MD: Yes, that's correct.
Host Amber Smith: Is that permanent, or is it reversible?
Roberto Izquierdo, MD: Unfortunately it's not reversible, so it is permanent. So at this time, the only way to treat it is through multiple daily injections of insulin. So we give a combination of a long-acting insulin that keeps the sugar from rising overnight and between meals, and a fast-acting insulin that,treats the rise in blood sugar after a meal that contains carbohydrates.
Host Amber Smith: Now, I understand more research needs to be done. But what do you think might be the connection between Type 1 diabetes and COVID-19 or the coronavirus?
Roberto Izquierdo, MD: We need more research to understand the mechanism. The cells in the pancreas, the beta cells, do have the ACE, or angiotensin-converting enzyme, in receptor 2 on their surface, so it could be that those cells are directly damaged by the COVID virus. The other possibility is our body's immune response to the COVID infection creates a whole host of chemicals called cytokines, and these cytokines help the immune system fight off the infection, but as a byproduct, they could also damage the beta cells.
So I think with time, we'll be able to figure this out a little bit more and to see what the exact causes are.
Host Amber Smith: Do we know yet if the kids who are fully vaccinated have a lower risk of developing Type 1 diabetes after COVID-19 than the kids who were not vaccinated?
Roberto Izquierdo, MD: I have not seen reports of that, but I'm sure that there will be, but we do know that, vaccines prevent the COVID infection.
And I think as a result that incidence of and prevalence of diabetes should decrease in these children once they're vaccinated. For example, kids that get vaccinated have less of the systemic inflammatory response that we see in some children weeks after the COVID infection. so I would expect that the vaccine would prevent COVID, and as a result, you have less incidence of Type 1 diabetes.
Host Amber Smith: But just to be clear you're seeing kids with new-onset type 1 diabetes who don't have any sort of family history of diabetes and don't really have any risk factors per se for diabetes, but they've had COVID-19.
Roberto Izquierdo, MD: That's correct. Yes.
Host Amber Smith: That's a little scary.
Roberto Izquierdo, MD: It is very scary.
In our own population here, the patients with newly diagnosed Type 1 diabetes have increased by 30%. In some places, like a report from a hospital in San Diego, it increased by 57%. So that's very alarming.
Host Amber Smith: I want to ask you about the symptoms of new-onset type 1 diabetes. What would these children, in your case, since you focus mostly on pediatrics, what would they be experiencing that would send them to the doctor?
Roberto Izquierdo, MD: The symptoms to look out for are frequent urination, thirst -- so, drinking a lot of water, unintentional weight loss, fatigue. We see a number of children that previously could make it through the night without bedwetting, and then they start wetting the bed.
Those are some of the signs that could trigger the parents to bring them to the pediatrician or the family doctor to have them checked.
Host Amber Smith: Are doctors looking at this as part of long COVID, because we hear about people who survive COVID, but then they're dealing with symptoms, lingering symptoms or new symptoms, fatigue mainly, months after?
Roberto Izquierdo, MD: Not to my knowledge. No, I think this is more like an acute event than like the long COVID that has been described.
Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but stay tuned for more information from Dr. Roberto Izquierdo about children who are developing diabetes after COVID-19 infection.
Welcome back to Upstate's "HealthLink on Air." This is your host, Amber Smith. I'm talking with Upstate's chief of pediatric endocrine and diabetes, Dr. Roberto Izquierdo. I'd like to have you walk us through how Type 1 diabetes is diagnosed. So if you have a patient who comes in, who's had frequent urination and increased thirst, and they've lost weight, how do you test to see what's going on?
Roberto Izquierdo, MD: We draw a blood test for blood sugar. There's another test called the hemoglobin A1C, that we use to monitor patients long-term. The A1C measures the amount of sugar attached to the red blood cells and the red blood cells circulate in the blood for about three months.
So if your blood sugar's high, that A1C will be high. So the normal sugar, no matter what you eat, in the blood, in someone without diabetes, between 70 and 126. If you get a fasting blood sugar on two occasions in which the blood sugar's over 126 that's considered diabetes. Or if you have a blood sugar over 200 with symptoms like drinking, a lot of water, urinating a lot, weight loss, that's also just on one blood test, you could diagnose Type 1 or Type 2 diabetes.
Normally the A1C in someone without diabetes is less than 5.7. So if the A1C is greater than 6.5, we diagnose also type 2 diabetes. So those are the two main tests, the blood sugar and then the A1C. We also check the electrolytes because, for example, someone has a child who's sick with fatigue, dehydration, lethargy, they may be in diabetic ketoacidosis. In that situation, we check the electrolytes, we check the bicarb, which is the buffer, and we also check the pH, the blood pH, and that helps us diagnose if the patient is in diabetic ketoacidosis. In that situation, then, you need more emergent treatment, so, if the patient's not in the emergency room, we do send them there to get hydration, and these patients then need to be admitted to provide fluids by vein and to provide insulin by vein to stop the ketones from being produced. And usually that could take, depending on the severity, eight to 12 hours.
Host Amber Smith: Would a regular pediatrician, because I'm imagining most people would go to their primary care provider first, would that person order those tests, or at what point might someone be referred to someone like yourself, who specializes in endocrinology?
Roberto Izquierdo, MD: Yeah, usually the pediatricians do. And the families are well aware of diabetes, so they can draw those diagnostic tests initially. Usually for patients with Type 1, especially children, we do get a referral in this area, for management, with insulin long-term.
Host Amber Smith: So someone who is sent to the hospital immediately to be regulated or stabilized, how long might they be in the hospital, and then what happens after that?
Roberto Izquierdo, MD: We're very lucky to have an excellent team here of diabetes care and education specialists, dietitians and also the inpatient hospital nurses that are well versed with the treatment. So most patients that need admission only stay for a day or so, and they go home the next day. If they're very young, and the parentsfeel a little bit uncomfortable, we may keep them an extra day because they do have to learn a lot, and I'm always amazed how well the parents do, and the kids, too, because within 24 hours, they go from not checking the blood sugar and not administering insulin to checking blood sugars, administering insulin, learning how to treat low blood sugars, how to check ketones, how to count carbohydrates because the dose of insulin is based on the carbohydrate content of the meal as well as the blood sugar before the meal. It does take a team to do that.
Our diabetes care and education specialists spend, for patients with new diagnosis, approximately three hours, you know, sometimes a little less and sometimes more, and then they meet with a dietitian to review carb counting.
Now, some kids that are not as sick. They just come to the office. And again, we're fortunate to have The DCES and the dietitian. So we see them within 24 hours and start insulin as an outpatient, and most families are able to do that. And then we also provide support after the diagnosis, once they go home. There's somebody on call 24/7 and the parents call for various issues.
We also provide information to them, like the "CalorieKing" book, where you count carbs, and the apps. And there's some basic diabetes books that are very useful, like the "Pink Panther" for children (so we provide that. I'm thanking the Upstate Foundation for that, for contributions.
Host Amber Smith: Now you used the term DCES.
Roberto Izquierdo, MD: That's the diabetes care and education specialist.
Host Amber Smith: I see.
Roberto Izquierdo, MD: In the past, it was called diabetes educator, but they do more than education because they adjust insulin and other things.
Host Amber Smith: Well, because this is a lifelong thing, a change in a child's life, but it's going to be with them for the rest of their lives.
So there is, I assume, a lot of learning to get right from the beginning, hopefully.
Roberto Izquierdo, MD: Yeah. And we do have a large population of patients, so we have close to about 1,200 children with diabetes in Central New York in more than 25 counties. And in this area, the proportion of Type 2 is much less, but we have like 500 patients over the past two years. We share that care; along with the doctors, we also have a team of nurse practitioners and PAs, physician assistants, that participate in their care. And fortunately, we do have a social worker and a child life specialist.
Host Amber Smith: Let me ask you: If a child, develops Type 1 diabetes and doesn't get care, is this a life-threatening condition for them, or what would happen?
Roberto Izquierdo, MD: Oh, it could be disastrous. If you don't treat the Type 1 diabetes, eventually you pass away because of lack of energy, you lose weight, you lose energy. So, before insulin was invented, patients with Type 1 diabetes would pass away. That was in the 1920s, so we have come a long way.
Host Amber Smith: It sounds like it.
Roberto Izquierdo, MD: Yeah.
Host Amber Smith: Earlier you mentioned that treatment usually is a combination of long-acting and short-acting insulin. I'm assuming that might be tailored individually to each person.
Roberto Izquierdo, MD: Right. Initially we base it on the patient's weight and the patient's age, but then we follow the pattern from day to day and day to week, and we make adjustments. Parents also learn how to do this. And over the past several years, there've been some great advances in the management of Type 1 diabetes, because now we have those continuous glucose sensors, like you see advertised, the FreeStyle Libre and the Dexcom, and then patients can also progress to a pump, which is the size of a small cellphone which you fill with insulin and you program it to give a small amount of insulin every hour. And then when, you need to eat, you tell the pump how much insulin to give just by pressing a button like you do on your cellphone What's great now, over the past couple of years, that you have these automated systems so it's really making a large difference in which the pump and the sensor, they communicate with each other. So it's automated. The drawback is that you have to have two sites, a pump site and a sensor, but, it does adjust the basal rate of the insulin given. So if your sugar is going low, it'll decrease the insulin administration or stop it temporarily, or if the sugars are going high, it'll increase the basal rates or give you a small bolus dose of insulin to bring the sugar down. So that's making a dramatic improvement in the management of these patients, as we've seen by improved quality of life, less low blood sugars, less high blood sugars. So it's very exciting.
There's more research being done in which we're looking into insulins that work faster. You might not even have to count carbs once that's developed. So I've seen dramatic improvement with those automated systems. I encourage all patients and families, but it's a personal decision, you know, for the family and the patient. I mean, some patients just do great with injections. Now we have insulin pens with very tiny needles, and some patients just prefer that, and they do just as well.
Host Amber Smith: I'd like to ask you how Type 1 diabetes affects a person's life in terms of, well, they're always going to be taking the insulin medication, but does this mean that they're restricted with their physical activities?
Roberto Izquierdo, MD: No, actually we encourage physical activity, and with good health care and taking care of yourself, like not smoking, eating a healthy diet, and as you get older, controlling your blood pressure and so on, you could live a very healthy life.
I have had a couple of patients, one patient passed when they were 95 and the other one 90 So they had diabetes for many, many years. So I think with good health care and good personal care, you can prevent a lot of the complications of diabetes, so no longer do you lose a toe or anything like that, with the current advances. Patients that had diabetes when they were diagnosed in like say, 1960, they may have complications, unfortunately.
Host Amber Smith: Do most of your type 1 diabetic patients come to see you annually or more frequently than that?
Roberto Izquierdo, MD: We try to see them every three months, so we alternate with the nurse practitioner or the physician assistant and the doctor, and then use a diabetes care and education specialist as needed and the dietitian as needed.
Initially we see them more frequently, so once you're diagnosed, we see the person about two weeks later. And then after that two-week visit, we see them a month later. And then usually it's three to four months.
Host Amber Smith: You've mentioned dietitian a few times, too. So does having diabetes mean that you're not going to be able to eat birthday cake or other sweets?
Roberto Izquierdo, MD: No, no. Nowadays, because we count the carbs in the food, you could eat all those sorts of foods. We just recommend for children a healthy diet. Just like I wouldn't want my children to be eating Snickers all day. That's not healthy for anybody. So they could eat cake, ice cream, they just have to give more insulin, so when they're going to do that, you count the carbs, which they learn how to do, and get the insulin dose via the pump or via an injection.
Host Amber Smith: You called Type 1 diabetes an autoimmune disease. And I wanted to have you explore that a little more. What does that mean to the person who's got the disease?
Roberto Izquierdo, MD: So autoimmune is like, it's the person's immune system attacks the cells, those beta cells. Now we don't completely understand that. We know that certain viruses can trigger that immune response, and some viruses have been found in the beta cells. For example, you could get a virus infection, and then that immune response then kills the virus, but also kills those beta cells. Now, why does this happen?
Some individuals are more predisposed to it, so they have a predisposition. So it's not strictly genetic, but there is a predisposition. So most patients that have Type 1 diabetes don't have a sibling that has Type 1 or parents, but there is an increased risk. So, if you have a child with Type 1, then maybe the risk goes up four times that their brother or sister may have it.
Now there are research studies trying to identify those patients because we could detect markers for in the blood that we check for, certain antibodies. If we see those antibodies, then they could possibly participate in some research studies to try to prevent progression. There's a lot of research in that area, though it's still in the research investigational field but at some point maybe we could even prevent the disease
Host Amber Smith: Does having Type 1 diabetes put a person at risk for developing other diseases?
Roberto Izquierdo, MD: Type 1does increase that risk because once you have an autoimmune disease, you may have another autoimmune disease.
So in those situations, we routinely check for thyroid disease; it's very common, underactive or overactive, mostly underactive disease. So we do that through a blood test every two years.
Celiac disease is very common, so we check for that too, especially in the first two years after diagnosis. And then some other conditions.
We want to monitor the cholesterol and triglycerides to make sure they're OK. We monitor blood pressure, because as you get older, managing all those comorbidities, what we call other conditions, keeps the complications at bay.
I always tell the residents (doctors in training) the ABCs of diabetes: A1C, blood pressure, cholesterol.
But there's other conditions that we monitor; patients with diabetes do tend to have a higher incidence of depression. So we would routinely screen for depression.
Now we're also monitoring for the determinants of health, the social determinants of health, the SDOH, because we know that non-Hispanic Blacks tend to have a higher incidence of diabetic ketoacidosis, compared to other groups. And so, by screening for those conditions, we can try to help them, help the family.
If you screen positive for a certain social determinant of health, like, say, maybe food insecurity, then our social worker can give them some resources to look into. If it's transportation, we could try to work to clear that because patients also that live in rural areas are at higher risk for diabetic ketoacidosis. And those that lack insurance are also at higher risk for diabetic ketoacidosis. So, we're trying to develop strategies to prevent diabetic ketoacidosis and also improve their blood sugars, so they have a lower A1C, for example.
Host Amber Smith: This has been a lot of information. So let me kind of recap: You're seeing, and endocrinologists like you across the country are seeing, an increase in the number of children who are diagnosed with Type 1 diabetes after having been infected with COVID-19. And this is a lifelong illness, if they're diagnosed with it, that takes some careful management, and the children who are vaccinated, that may offer some protection toward this, but that's kind of unknown because it hasn't really been explored entirely.
So there's more research to come, likely. If someone is diagnosed, a child is diagnosed, and they come to see you as a pediatric endocrinologist, do they stay with you throughout their life, or once they turn 21, do they get an adult doctor?
Roberto Izquierdo, MD: Usually they get an adult doctor. With me, I'm a pediatric and adult (doctor), so they stay with me as long as they want to stay. In our practice, once they reach 21, they get transitioned to the adult practice. So that may be our practice here, or they may decide to see another local physician. So we have developed a transition program to try to teach adolescents and young adults how to transition to adulthood, like for example, to learn how to navigate through the health insurance -- you know, it can be complicated -- and also discuss other issues that are pertinent to late adolescence or young adulthood.
Host Amber Smith: Well, Dr. Izquierdo I really appreciate you making time for this interview.
Roberto Izquierdo, MD: Oh, thank you very much and have a good day.
Host Amber Smith: My guest has been Dr. Roberto Izquierdo. He's a professor of medicine and of pediatrics, and he's the chief of pediatric endocrine and diabetes at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from psychiatrist Dr. Christopher Lucas from Upstate Medical University. How can someone avoid becoming addicted to their cellphone?
Christopher Lucas, MD: Well, the most basic step is to try and limit the use -- maybe set an alarm or a schedule for how often you will check your phone. Sometimes people are already checking it every few minutes. Then say, OK, I'm going to check it every 15 minutes. And then you could move to unchecking it every half hour, then every hour. And then once you set an alarm, then you could spend that time looking through any emails or notifications and then reset your timer. Now people will get anxious about not responding quickly enough, so you could head that off by letting friends or family know that you might not respond to their messages as quickly as you used to.
The phones have been manufactured to do things called push notifications, where you get a little chirp or pop-up screen when something happens. You don't need to be interrupted by every "like" that your Instagram picture gets or that someone has just released a new episode of your favorite podcast. And so, turn off push notifications for as many apps as you can, and really leave the notifications only for the ones that you absolutely need, such as an email or a calendar reminder. And then for other things, only have the notifications for when you're using the app themselves.
People tend to use phones in a sort of distracted way. So they go from one thing to another, to another, and they never really planned to go and check the weather, but they see the app for it. So take distracting apps off your home screen. Put them on a secondary screen or within a folder. Someone also had a suggestion of turning the icon from colorful and engaging to boring and gray, and there are options within the accessibility functions on your phone that would allow you to do that. You might actually want to delete certain apps that are particularly time-wasters or ones that seem to affect you negatively in terms of your mood or yourself esteem.
I think one of the most pernicious components of using cellphones is using them late at night whilst you're in bed just before trying to get to sleep. Although there have been some efforts to try and reduce the light emissions and the spectrum of the light that doesn't affect sleep, just using the phone prior to sleep is likely to make it harder to sleep. Phones and bedtime are definitely a danger area. So don't have the phone be the first thing that you check in the morning or the last thing you look at at night. Just use the regular alarm clock. Charge your phone outside of your reach. And you then won't, potentially, get tempted to use your phone first thing and get stuck in a whole bunch of messages.
If you have a smart speaker, such as an Amazon Echo or a Google Home, you might want to use that. You can ask the questions about what's the weather, or what's the traffic rather than having to go and interact with your phone.
And finally, as in anything where you're trying to monitor or change your pattern of use, you need to keep an eye on how much you're actually doing that. So there are a bunch of apps, like Quality Time or Moment, that can track your smartphone habits. What are you using? How are you spending your time? And then you can set specific goals and then see how well you are sticking to it.
It's obviously a difficult thing to do, and I struggle myself sometimes to put the phone down when I should be doing other things. But it's always tricky process because all of these phones and all of this software and all of this social media is engineered to try and get you addicted, to keep using so that you'll buy more phones, you'll upgrade your phone, and you'll provide more advertising dollars to the various sites that you look at.
Host Amber Smith: You've been listening to psychiatrist Dr. Christopher Lucas from Upstate Medical University.
And now, Deirdre Neilen, editor of Upstate's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Nancy Geyer is a writer from Washington, DC, whose work has appeared in the Georgia Review, the Iowa Review and New England Review. She sent us a poignant essay about caring for a parent who's experiencing cognitive decline. Here's her essay, "Heathens for the Day," which reminds us how illness spreads suffering throughout a family.
When I arrive at his house with a suitcase, my father leads me upstairs to L's bedroom and says, "I trust this will be satisfactory?"
He sometimes speaks in such formalities, jokester that he can be, but these days, I'm not sure what's what. Is he playing the proprietor of a rooming house because he needs time to figure out which daughter I am? Should I pretend it's only a joke and act the paying guest?
L, my half-sister and twenty-nine years my junior, is away at college. It's late in the evening, so I read for a while in her bed, then turn off her bedside lamp. There are glow-in-the-dark stars on her ceiling, as there were on mine long ago. I can't discern any familiar constellations, though. Maybe L, unlike me, attempted to arrange the stars herself, our father sensing, even then, that he was not up to the task. Or maybe what's up there is accurate, a part of the sky I don't know.
In the morning, when I go downstairs, my father looks befuddled by my presence. I don't want to risk offending him by stating who I am, so I casually ask if he's brought in the newspaper. He looks in his study, where there's a note on a whiteboard to remind him that his wife is away, and concludes that he has. After opening the front door and peeking out, he puts on his raincoat and unfurls an umbrella to fetch the paper from the far end of the front walk.
"You'd think they could have tossed the paper a little closer to the door," I say when he returns, dripping. My words are met with silence.
After I shower and dress, my father, who now sleeps on the first floor, comes upstairs and calls out "Hello." I go out into the hallway to let him know that he and I are the only ones at home. He's changed into a jacket and bow tie.
Oh no. He thinks we're going to church. The newspaper must have reminded him; he relies on it as a calendar, somehow remembering to drop it into the recycling bin each night. But I'm not sure how to get to his church. I doubt he even goes anymore.
I fear that my father, a retired professor and Methodist minister, will tell me they're expecting him, that he must take his place in the choir. But instead he says brightly, "So we're going to be heathens today?"
Thank God. "Yes," I say, "we're going to be heathens today!"
I ask him if he's had breakfast and he says he can't remember. So I make toast and he sprinkles it with cinnamon sugar. When we've finished eating, he clears our dishes from the table and washes them. He never did these tasks while I was growing up. Perhaps running water and a plate in his hands give him a purchase on the here and now.
An hour or so later, I remind my father that he wanted to shave. He goes upstairs to the master bathroom. I wait a few minutes and then go up to see if he's found his razor and shaving cream. "I wasn't looking for them," he replies, clearly annoyed. Stubble agitates him, makes him imagine a full beard, so I gently tell him again that he had told me he wanted to shave. Silence. Later, back downstairs, when I ask him if he'd shaved, he feels about his face and says, with obvious satisfaction, "Why, yes I did!"
This is how the rest of the morning goes, and then the afternoon, each of us feeling our way.
For dinner, I take the easy way out in order in Chinese food, my father's favorite. He begins his meal by unwrapping and cracking open his cookie. A child might do this -- reach for the cookie first -- but my father's main interest seems to be his fortune. "You can have anything you want if you want it desperately enough," he reads aloud.
"That's not very helpful," I say.
"No, it isn't," he responds.
We eat the main course and then he picks up the fortune again, as if for the first time. "Not true," he finally says. But before that sour thought has a chance to hang around, an ice cream truck goes by to the tune of "Old MacDonald Had a Farm." My father leaves his chair and rushes to the piano to accompany the truck as long as it lingers in the neighborhood, which is for quite a while. He plays in plays and we sing and sing, our song stuck on repeat.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air": monkeypox and a look at irregular heart rhythms. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air "is produced by Jim Howe, with sound engineering by Stephen Shaw. This is your host, Amber Smith, thanking you for listening.