What to consider if you are diagnosed with -- or at risk for -- pre-diabetes or diabetes
Transcript
Host Amber Smith: Upstate Medical University in Syracuse New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Many of the people who have diabetes are undiagnosed and untreated. This is a disease that can have an impact on all sorts of other conditions, so being aware that you have developed diabetes or that you are at risk is important. Here to explain why is Upstate family nurse practitioner Dana Lonis and Peter Rosher, who's a pharmacist specializing in endocrinology. Welcome to "The Informed Patient", both of you.
Nurse practitioner Dana Lonis: Our pleasure.
Pharmacist Peter Rosher: Thank you.
Host Amber Smith: I've heard that up to one in three adults has prediabetes. Can you tell us what that is? Ms Lonis?
Nurse practitioner Dana Lonis: Sure. So prediabetes is a serious health condition where the blood sugar level is higher than normal, but not high enough to be diagnosed with the disease. A normal -- we use an A1C (hemoglobin) level -- is below 5.7%. A level between 5.7% and 6.4% indicates prediabetes. And if you're higher than that, then you would be diagnosed as a person living with diabetes.
Host Amber Smith: So if someone's provider tells them they have pre-diabetes, that doesn't necessarily mean they will develop diabetes. They can take action to turn things around, it sounds like.
Nurse practitioner Dana Lonis: Yes, they can. The link for that person being likely to develop diabetes is there, however. So it's definitely a precursor to type 2 diabetes, and we want to make sure that people take that very seriously. Like I said, it is a serious health condition where your blood sugar level is higher than normal. It hasn't gotten to the point where we're going to diagnose you with diabetes, but it's telling us we have to make changes.
Host Amber Smith: So how do people usually learn that they have prediabetes? Are there symptoms that bring them to a doctor's or a nurse practitioner's office?
Nurse practitioner Dana Lonis: There are definitely symptoms associated with type 2 diabetes. A lot of times in the pre-diabetes phase, folks will not have symptoms, so these numbers will be picked up on screenings at your primary care physician. A lot of times people do not know that their numbers are abnormal because they're not high enough to create symptoms at that point.
Host Amber Smith: Now, is this a concern for adults, or would children, perhaps, be diagnosed with pre-diabetes as well?
Nurse practitioner Dana Lonis: In the past, type 2 diabetes was also known as adult onset diabetes, because most people developed it later in life. But increasingly, certain lifestyle choices and habits have put children at risk for prediabetes and type 2 diabetes. Both the CDC (Centers for Disease Control and Prevention) and the American Diabetes Association have identified what these risk factors are. They mostly include being overweight and not being physically active.
Host Amber Smith: So at the point of pre-diabetes, Mr. Rosher, are there any medications that may be prescribed for someone at this point?
Pharmacist Peter Rosher: Yes, there are. One would be metformin, depending on the risk, but I think the biggest factor if you're pre-diabetic would be lifestyle changes, things like exercise and diet education would help with trying to prevent the onset of diabetes and reverse prediabetes.
Host Amber Smith: Now, you used the word metformin, and I've heard that before. It's of common medication, but what is it and what does it do?
Pharmacist Peter Rosher: It helps with the sensitivity of insulin that your body already makes. It's pretty benign. The biggest side effect of it may be some GI (gastrointestinal) irritation, some nausea, vomiting, increased bowel movements. But it is generally well tolerated, has been around for many years, and I think that, if it's needed, it is a great medication. And it's relatively inexpensive.
Host Amber Smith: Well, Ms. Lonis, what are the most common signs and symptoms that prediabetes has evolved into Type 2 diabetes? What do you monitor to tell when that has happened with somebody?
Nurse practitioner Dana Lonis: So if you're looking for the symptoms for when a person's actually coming into the disease, you're going to look at what we call the three P's -- increased thirst, increased or frequent urination and increased hunger. Other signs and symptoms could be fatigue, blurred vision, numbness or tingling in your feet or hands, frequent infections, slow healing ulcers or sores, and, occasionally, unintended weight loss. The three Ps that we speak of are more medical terminology, which is polyuria, polydipsia, and polyphagia, which are the three things that I just described.
The other thing that primary care providers want to keep an eye out for is any darkening of the skin, in skin folds or in the underarms. This is often due to a condition called acanthosis nigricans, and it causes your skin to be thick and dark in the folds in the body. Carrying extra weight makes your body more resistant to the effects of insulin. High levels of insulin in your blood can lead to increased production of skin pigment cells. So if you're seeing that in yourself or in a patient, you would want to report that to your primary care so they can then check an A1C to make sure that you aren't a person who is in the pre or diabetes phase.
Host Amber Smith: You listed a lot of signs and symptoms. Do most people have more than one of those?
Nurse practitioner Dana Lonis: Most people, if they're living with pre-diabetes, probably have no symptoms at all, other than if you are overweight with a BMI (body mass index) greater than 25, you should be screened for prediabetes and diabetes yearly. Um, but those other symptoms, yes, you will oftentimes have those together. The thirst, the frequent urination, the hunger, fatigue, blurred vision, those things a lot of times will be together.
Host Amber Smith: You said the A1C. Is that a blood test?
Nurse practitioner Dana Lonis: Yes, ma'am. It's a blood test. It's a blood test that tells us essentially how much sugar is attached to hemoglobin A in your blood. And it gives us a percentage, which we then use to categorize what your blood sugar's been doing over a three-month period.
Host Amber Smith: So I know diabetes seems to be all about blood sugar...
Nurse practitioner Dana Lonis: Mm-hmm.
Host Amber Smith: ...but it's the pancreas that makes the insulin. So how would somebody know that their pancreas was working effectively, or if it wasn't?
Nurse practitioner Dana Lonis: Well, a screening at at your primary care is extremely important, which will show us blood levels of glucose. But if you're looking to know, after you've been diagnosed, what blood tests can be done to see if your pancreas is still making insulin, we have a blood test called the C Peptide. And it's measured to tell the difference between insulin that the body produces and insulin that's injected into the body. We use that, oftentimes, in the hospital environment, especially, to try to delineate between type 1 diabetes and type 2 diabetes. But your C Peptide level will be able to generally tell us if your body is still producing insulin or if your pancreas is still producing insulin.
Host Amber Smith: What effect does diabetes have on the heart and blood vessels?
Nurse practitioner Dana Lonis: Well, high blood sugar comes, oftentimes, with other things that it's associated with, such as high triglycerides, high blood pressure, high cholesterol, overall. All of these things can damage your blood vessels and nerves. They can damage the small blood vessels that nourish your nerves with oxygen and nutrients, and they can also promote atherosclerotic disease in your larger blood vessels.
Host Amber Smith: And what does diabetes do to the kidneys?
Nurse practitioner Dana Lonis: Well, the blood vessels inside your kidneys, they are millions of tiny blood vessels. So over time, high blood sugar can cause those vessels to become narrowed or even clogged. Of course, if your kidneys aren't getting enough blood, the kidney then becomes damaged, and we can see that by the buildup of something called albumin, which is a protein that passes through those tiny little filters in your kidney and ends up in your urine. So we oftentimes will, in those screening phases, we'll check your urine for any type of protein or albumin
Host Amber Smith: This is Upstate's "The Informed Patient" podcast with our guest, Dana Lonis, who's a family nurse practitioner at Upstate, and Peter Rosher, who's a pharmacist specializing in endocrinology. Our subject today is management of diabetes.
Mr. Rosher, I'd like to talk now about how diabetes type 2 is treated. What medications are typically used, and what do they do? You already told us about metformin, but are there some other common ones?
Pharmacist Peter Rosher: Yes. First of all, they would probably start with some drugs called (sodium-glucose cotransporter-2) SGLT2 inhibitors and (glucagon-like peptide 1) GLP-1 agonists. And they are the forefront of diabetes therapy right now. But the downside is they're a lot more expensive. They will also use sulfonylureas, and they are cheaper and older, but still very good. The downside with those is that you might become hypoglycemic. So, every plan that is developed for patients has to be patient specific of what they can afford and what side effects they can tolerate. So each plan is individualized per patient.
Host Amber Smith: If someone starts taking an insulin for diabetes, is this a lifelong medication that they'll always be taking an insulin?
Pharmacist Peter Rosher: Great question. Not always. If it's type 2 diabetes, then you're able to make lifestyle modifications through diet and exercise, you can likely come off insulin, with a reduction in weight. If you are a patient with type 1 diabetes, then you produce no insulin, and you would need to be on some form of insulin.
Host Amber Smith: So, have you ever seen a patient get their diabetes under control and be able to come off the medications that they've been taking?
Pharmacist Peter Rosher: Yes. Some people are very determined and make huge lifestyle modifications and are able to reverse their diagnosis of diabetes and just treat it with diet and exercise.
Host Amber Smith: I've heard about insulin pumps, and I'm wondering what can you tell us about how well those work for people and if they're being used across the board?
Pharmacist Peter Rosher: They are one of the great modern medicine advancements that we've had in the last 20 years, and you're able to basically mimic a pancreas, not completely yet, but 90% of the way. It tackles your hepatic blood glucose production by giving insulin throughout the day. And then if you're eating, it can administer, extra bolus doses to attack the carbs that you're eating in your meals. And then in combination with continuous glucose monitors, that monitor your blood glucose continuously, there can become some systems that are closed loop and can even adjust the insulin pump based on your current blood sugar.
Host Amber Smith: Are most people with diabetes candidates for using a pump?
Pharmacist Peter Rosher: There's a lot involved with it. It is intensive therapy. You have to be cognitively evaluated to be able to manage it. Some people find it easy, and other people find it more difficult, so it's, again, patient specific.
Host Amber Smith: Ms. Lonis, what concerns do your newly diagnosed patients have?
Nurse practitioner Dana Lonis: Well, it's overwhelming. And people are scared and nervous about what the next steps are. So reassuring them that there are many proven ways to tackle this disease, and that there is a community that they can fall back on, you won't have to maneuver this disease by yourself. You have this support of countless others who have felt the same shock you're feeling. And that there are, generally speaking, a regimen for anyone. So, like Pete was describing, some people will want to use the advanced technologies of a pump. Some folks would want to do more traditional types of diabetes regimen. No matter what your lifestyle preference is, we can generally find a regimen that will work for you.
Host Amber Smith: Let's talk about complications that can develop from diabetes that is not properly managed. What types of issues are the most common that you try to warn your patients about?
Nurse practitioner Dana Lonis: Well, the most common things are going to be macro or microvascular damage. And those things can lead to very serious complications, as we've already discussed. We can have kidneys that don't function properly. We can certainly have eye damage, nerve damage, liver disease, heart disease, stroke. Oftentimes we call the ABCs of diabetes -- the A1C is the A, the B is blood pressure, and the C is cholesterol -- so the high blood pressure and the cholesterol elevation are also, oftentimes, diagnosed at the same time diabetes is diagnosed. Those are very serious complications, if you don't manage your diabetes properly, that you will be faced with.
Host Amber Smith: I'd like to ask about risk factors for diabetes. Does this disease run in families?
Nurse practitioner Dana Lonis: It does run in families. And there are risk factors. Mostly, two that I already described, which is a sedentary lifestyle, and being overweight. Also, having high blood pressure, high cholesterol. If you use alcohol, heavy use of alcohol can also be associated, and some adults who haven't gotten the proper sleep have also shown to be more likely to develop diabetes. So those are certainly some risk factors.
And as far as running in families, it has been shown, especially with a person living with type 2 diabetes, that that can run in families. What hasn't been shown is exactly what the link is and whether or not that is just related to the fact that most families eat the same or maybe don't exercise enough together. We aren't exactly sure of that link. I hope that answers your question.
Host Amber Smith: Well, what is your best advice for how to prevent diabetes? I know you're going to say to be active and...
Nurse practitioner Dana Lonis: Mm-hmm.
Host Amber Smith: ...maintain a healthy weight. Are there particular foods to avoid or particular foods to eat, or anything other that someone can do to take action to hopefully prevent diabetes?
Nurse practitioner Dana Lonis: Certainly, as you describe, having an active lifestyle is one of the best things you can do. If you're in the pre-diabetes phase and you're overweight, obviously losing weight is very helpful. Choosing drinks that do not have sugar. if you're going to eat high carbohydrate foods, maybe higher fiber carbohydrates. Cutting down on red or processed meat. Eating plenty of fruits and vegetables. Be sensible with alcohol. And maintain a healthy weight, a BMI less than 25, maybe greater than 18.5.
Host Amber Smith: Well, that's helpful advice. I want to thank both of you for making time for this interview.
Nurse practitioner Dana Lonis: My pleasure.
Pharmacist Peter Rosher: Thank you. My pleasure.
Host Amber Smith: My guests have been Dana Lonis. She's a family nurse practitioner at Upstate. And Peter Rosher. He's a pharmacist specializing in endocrinology. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. This is your host, Amber Smith, thanking you for listening.