Studying balance through taekwondo; vein disease; ways to receive insulin: Upstate Medical University's HealthLink on Air for Sunday, May 12, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," physical therapists explain how the martial arts may help with balance and mobility.

Molly Torbitt, DPT, PhD: ... There are some age-related changes that can affect how well our muscles fire, how quickly they fire, and it makes it easier to not move when things aren't functioning properly. ...

Host Amber Smith: A chief resident provides an overview of superficial venous diseases.

Anderson Anuforo, MD: ... If there's a need for intervention, and nothing is done, it can get quite serious and can affect people's quality of life significantly. ...

Host Amber Smith: And a diabetes specialist tells about new insulin delivery systems.

Ruth Weinstock, MD, PhD: ... One of the great things about these automated systems is that they do reduce time that your blood sugar goes too low, hypoglycemia, because it suspends insulin delivery if it senses that you're going to go too low, and people have a much greater time in the normal range. ...

Host Amber Smith: All that, 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, an overview of superficial venous diseases. Then, a look at new methods of delivering insulin. But first, physical therapists are seeking volunteers for research into whether martial arts can improve balance and mobility.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

So much of what we do requires good balance, and balance is crucial if we want to maintain our mobility. A pair of physical therapists at Upstate have launched a study that examines whether martial arts practice can build and maintain balance and mobility.

With me to talk about their work and how you can get involved are Dr. Bokkyu Kim and Dr. Molly Torbitt. They're both assistant professors in Upstate's College of Health Professions.

Welcome to "HealthLink on Air," both of you.

Molly Torbitt, DPT, PhD: Thank you for having us, Amber.

Bokkyu Kim, PT, PhD: Thank you so much.

Host Amber Smith: Now, I've seen flyers for your study online. Why is it called Kick Silver Program? Dr. Kim?

Bokkyu Kim, PT, PhD: So actually, I brought this name from a Marvel Comics character, which is Quicksilver, which is moving really fast. And I'm using the martial arts, specifically taekwondo, which is using fast kick movement in order to improve your physical function as well as your cognitive and other body functions.

Host Amber Smith: I see. Now from a physical therapy point of view, just how important are balance and mobility? Dr. Torbitt?

Molly Torbitt, DPT, PhD: Balance and mobility are super important, especially as individuals get older. We know that there are some age-related changes that can affect how well our muscles fire, how quickly they fire, and it makes it easier to not move when things aren't functioning properly.

So, this study in particular, we're using kind of a novel intervention to deliver balance and strength training in terms of being able to be on a single-leg stance -- you know, being on one leg -- building the strength and the mobility that people need to function throughout their later years.

Host Amber Smith: So these age-related changes, is this a natural occurrence that happens for everyone as they age, balance is more of a challenge, mobility may be more of a challenge?

Molly Torbitt, DPT, PhD: Yes. So as people get older, just from an aging standpoint, we lose muscle fibers, right? So they're not recruited as quickly, so we can't call on them to do their jobs as well. But what's nice is that we know that, through training, things can be reversed so that people can stay functional for longer periods.

Host Amber Smith: So there is a way to try to prevent or stave this off a little if you are active or training.

Molly Torbitt, DPT, PhD: Correct.

Host Amber Smith: Well, let's talk about your study. What made you choose martial arts to examine? Dr. Kim?

Bokkyu Kim, PT, PhD: So I've been training taekwondo about one year and nine months now. As a physical therapist, we always tell our patient, you have to move more. You have to be active, you have to use your strengths, you have to use your muscles to move, right? And as a physical therapist myself, I want to do something in order to say to my patient that you have to move.

And then the exercise that I chose was taekwondo because I was able to do this with my son, who is a second grader. And then I want to do something that I can do with my family. And my son was practicing taekwondo for a year at the time, and then they had some family class, so I joined as a trial, and then I really enjoyed it. It was really fun. And then I was able to feel that I regained my muscles and then, even, I don't have any, like, physical disability or any conditions, but that I was not active enough.

So I was able to feel that I am regaining more muscles. I was able to feel that. And then, I want to share the feeling with others, especially older adults, who are losing their muscles.

And recently I read an article saying that 1 kilogram, which is about 2.2 pounds of muscle mass, is worth about $10,000 for older adults because if you have more muscles, you maintain your balance. You don't have any falling, which is consequently forcing you to pay for medical care. But if we have a decent amount of muscles, we can prevent these falls, and then we can save our money.

Host Amber Smith: That's an interesting way of looking at it. Your study, how is it designed, and what type of people are you looking for to participate?

Bokkyu Kim, PT, PhD: This is more like a feasibility study. As of now, we are looking for five healthy, non-disabled older adults who are aged between 65 and 85, and also people with Parkinson's disease, especially those with mild to moderate severity of Parkinson's disease. As a feasibility study, we want to demonstrate that this taekwondo exercise program is safe and also effective to improve their balance and mobility, in all the older adult population, as well as people with Parkinson's disease.

Host Amber Smith: So the people who volunteer will all be taking a martial arts-type of training class over a period of time. Is that right?

Bokkyu Kim, PT, PhD: Yes. This is designed as a crossover design. In other studies, you may have, like, control groups who don't receive the treatment or exercise, and the experimental group, where they get these treatments or exercise.

But in our study, we have crossover design. So, the first two months they don't get any exercise, but we have some assessment of their balance and mobility at two different time points with two months' time difference. And then they're going to participate two months in a taekwondo exercise program.

And then we are going to have another assessment of their balance and mobility, so we can compare, within the same group, whether they have any improvement in their balance and mobility -- without exercise or with exercise.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking about a study of balance and mobility with two physical therapists at Upstate, Dr. Bokkyu Kim and Dr. Molly Torbitt.

So you'll have 10 participants, five who maybe have Parkinson's and five who are considered healthy adults, for comparison's sake. And for how long will this trial of martial arts extend? How many months or weeks will this take?

Molly Torbitt, DPT, PhD: The actual taekwondo bit of it will be over 16 sessions, so participants will attend two weekly sessions over eight weeks, and then when they're done with that, we will reassess everything that we did when they initially joined the study, and then two months after prior to starting the taekwondo. And then we'll reassess everything at the end.

And we also plan on doing interviews with people to get their viewpoint, right? So not only do we want to know, is it feasible, right? So can it be done, but we also want to know, do people enjoy it?

And then from there, we want to do it on a larger scale to really flesh out, like, how often is it needed to actually see those changes and improvements? How intensely do people have to exercise to see those improvements? Those are the kind of things that we'll be looking to, moving forward.

Host Amber Smith: Now, who teaches the classes?

Bokkyu Kim, PT, PhD: We are in partnership with Master McDowell's taekwondo school in Manlius. There are amazing taekwondo instructors in there. And then participants will be joining regular adult classes in the taekwondo school. So they will be practicing taekwondo with other students, adult students in taekwondo school, but it will be more individualized. In taekwondo school, everyone gets more individualized instruction based on their level, then based on their physical capability.

So even (though) they are joining the regular classes, it will be more modified in order to meet their requirements, meet their physical capability.

Host Amber Smith: Well, that's what I wondered. When people are applying to be participants in this, are you going to look at their fitness level? Because you may get people who haven't been very active, and you may get people who run marathons. So does it matter, for the purposes of your study, what sort of fitness background that people have?

Molly Torbitt, DPT, PhD: No, it doesn't matter, right? Because when we are doing our pre- and post-testing, we're looking at it within each individual person. And a lot of these tests that we're doing have what they call a minimum detectable change, where that person has to improve by such and such amount, and so what it looks like in maybe a more trained individual, they still have to improve by the same amount that an untrained individual would. So it's all relative to that individual person.

Host Amber Smith: Well, let's tell listeners where they can go to learn more. They can send an email to Dr. Kim at [email protected], and then you can respond to people with more information about how to sign up, or apply.

Now, why would you say that people should consider joining the study?

Bokkyu Kim, PT, PhD: Taekwondo exercise has a lot of benefits. First of all, in textbooks of taekwondo, it says taekwondo spirit is to overcome your limits and benefit the world.

And if you have any physical limitations, you tend not to move, but we want those people to challenge themselves using a taekwondo exercise program, so they can feel that actually they can improve their physical function to prevent further falls or to be more engaged in physical activities, and then to be more participating in community activities, et cetera.

So, that is the priority of our purpose. And also taekwondo exercise, you know, many older adults, they are doing a lot of physical activities, and then sometimes they start some of those activities, and then they stop because it is getting boring.

And some exercises, we need to motivate those people to continue. And then taekwondo, they have a belt system. You are starting with white belt, and then as you progress, you can get yellow belt, green belt, blue belt, red belt and even at the end, you can get the black belt. And that system can motivate you to pursue further advances in your journey of physical activity. And so there could be more benefits.

And then there are a lot of different components of taekwondo exercise, like they are using a lot of loud shouting, which is also beneficial for your physical function and especially people with Parkinson's disease.

And then, as Dr. Torbitt mentioned, it is using a lot of one-legged stances, so it is challenging your body to maintain your balance. Even with one leg, it would be more beneficial to maintain your balance while you are walking or while you are doing some other activities.

Host Amber Smith: I wanted to ask you a little bit more about the actual workouts. Is it a full-body workout? Are you working mostly on kicks in the lower body, or is there some upper body as well?

Bokkyu Kim, PT, PhD: Yes. In taekwondo you do a lot of punches. It is a different style of punching compared to boxing, but still you have to maintain your balance. And then you do a lot of punches with your upper extremities or upper body, not just practicing those techniques and skills, but also doing some high-intensity interval training, which is beneficial to improve your cardiovascular function.

And also there's another specific curriculum of taekwondo, which is called poomsae. Poomsae is more like a choreographed movement pattern, so you can think this is kind of similar to tai chi, but it is using more dynamic, powerful kicking and punching motions. So it is more beneficial, especially in people with Parkinson's disease, to amplify the brain activities. It is more theoretical; we have to prove scientifically whether this poomsae practice could be beneficial to boost your brain activity. But sometimes people with Parkinson's disease, they have that reduced activity of the brain, and using this exercise in taekwondo poomsae, we can actually enhance brain activity. And also it is using a sequential movement pattern, so it can be also challenging to their cognitive function, so it can be also beneficial for improving their cognitive function.

Host Amber Smith: It sounds like you'll get a cardio workout, and it sounds like there's some flexibility. Would you consider this is also some strength training, body-weight strength training?

Molly Torbitt, DPT, PhD: Yes. So there is definitely a strength training component to this, right? We need to be able to support ourselves in single-legged stance to do these kicks and to do these punches.

And we need to be able to maintain the proper stance -- position -- right? The base of support that they're using. You need to be strong and stable in that so that you can do these movements and progress through those sequences. So, depending on the nature of the course that day, there might be a designated strength-training component.

I spent a couple years training in karate, and there were times where we would pick up weights, and we would do our punches and our kicks with weights in our hand. And while it's not necessarily part of the actual choreographed sequences, it has its own place in the course to make your movements more crisp, to make them more powerful.

So yes, there is, depending on the nature of the course that day, there can be a strength component as well.

Host Amber Smith: Now, do the volunteers in the study, do they pay for the training class, or is that included -- because they're volunteering, is the fee waived?

Bokkyu Kim, PT, PhD: We have a small funding for now, so we can pay for their tuition for taekwondo school.

So it would be completely free for our participants to join the class for two months, and then after two months, if they want to continue, maybe they can pay by themselves. But for this two-month time period with us, we will be paying their taekwondo school tuition. And also there's a belt test (advancement test) at the end of the two-month program, and if they are eligible to get belt test, we are going to pay the belt test fee as well.

Host Amber Smith: Do they need any special equipment or special clothing, or how do they need to dress to come to the classes?

Bokkyu Kim, PT, PhD: Every taekwondo school, you have to wear a special uniform, which is called dobok, and then we will be providing these uniforms for our subjects, and also, if you need any protective equipment, we will be providing these to our participants.

Host Amber Smith: Well, I'll remind listeners again to send an email to Dr. Kim at [email protected] if they want to learn more about this or participate. I appreciate both of you making time for this interview, Dr. Kim and Dr. Torbitt.

Molly Torbitt, DPT, PhD: Thanks again Amber. We really appreciate you having us on today.

Bokkyu Kim, PT, PhD: Thank you so much.

Host Amber Smith: My guests have been Dr. Bokkyu Kim and Dr. Molly Torbitt. They're both assistant professors in Upstate's College of Health Professions. I'm Amber Smith for Upstate's "HealthLink on Air."

Varicose veins and other superficial venous diseases -- next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Superficial venous diseases are a broad group of venous vascular disease that predominantly affect the body's lower extremities.

I'll go over the most serious of these manifestations with Dr. Anderson Anuforo. He's a chief resident in internal medicine at Upstate Medical University.

Welcome to "HealthLink on Air," Dr. Anuforo.

Anderson Anuforo, MD: Thank you so much for having me, Amber. It's my pleasure to be here.

Host Amber Smith: When we talk about superficial venous diseases, what does that include?

Anderson Anuforo, MD: So there are a couple conditions that are classified. There's a classification system that's from C1 to C6, and every one of those conditions are classified under superficial venous diseases.

So the way it progresses typically would be, it would start out something like, they call it a ... the medical name is not really important, but it's a very small vein, the smallest vessels, kind of like a star, and it all spreads out from the center, and that's the C-1.

And then it goes on to become a varicose vein. And that is commonly seen, it's deep blue, you see it under the skin, it's bulging, a little tortuous, kind of like veins clumping together. So that's kind of the next stage.

And after that, the leg gets a little bit more swollen. That's what they call venous edema. So it's basically leg swelling, and then it begins to get a little more discolored, darker.

And after that, if nothing is done at that point, it goes on to get some ulceration. And that's kind of like the last stage.

And sometimes it can get really bad. Thrombosis, that's a blood clot basically in the superficial veins. The common thromboses we tend to talk about are what we call deep vein (DVT, or deep vein thrombosis). The ones in the deep veins, like after long (airplane) flights, stuff like that. In these ones they have blood clots in the very superficial veins overlying the skin.

And that's another category of conditions that are classified within superficial venous disease.

Host Amber Smith: Varicose veins -- I've heard of that. Is that what you just described?

Anderson Anuforo, MD: Varicose veins are the ones in which the veins just under the skin. Typically, you would just see, like, a dark line, long dark line.

In this case, varicose veins are more serpentine and swollen and then distended, and it's more on the lower extremities, the legs and the thighs, because of the pressure. So people who stand upright for a long time tend to have it more from all that pressure of blood having to go against gravity.

Host Amber Smith: And I've also heard of something called chronic venous insufficiency.

Does that get dealt with as a superficial venous disease?

Anderson Anuforo, MD: It definitely is. It definitely is. So, if the pressure in the venous system is very high, over time, because veins have valves, which help to ensure that blood flows in just one direction, from the body to the heart, unfortunately, due to certain conditions, a bunch of things could make that happen. The veins become incompetent, so they don't work as they should. And so there's a reflux. Blood flow goes backwards. Instead of going forward towards the heart, it goes backwards again due to the high pressure. And that's what chronic venous insufficiency basically is, that incompetence of the valves.

Host Amber Smith: As you're describing this, it sounds to me like some of these conditions can be serious. Is that right?

Anderson Anuforo, MD: Oh, yes. Yes, at the early stages, not as serious. But if nothing is done for some people, if there's a need for intervention, and nothing is done, it can get quite serious and can affect people's quality of life significantly.

Host Amber Smith: So at the earlier stages, is it considered a cosmetic thing, and if you just take care of it, it won't get worse, necessarily? Or is it a condition that isn't cosmetic, but it does need to be treated?

Anderson Anuforo, MD: At the early stage, actually, it is more cosmetic than anything. But there are some questions that you would ask patients or individuals who find this, like, do they have any of the risk factors for the progression of the disease?

And if they do have those risk factors, then some of them might need to be treated sooner rather than later.

It's very, very prevalent, actually. Millions of people have it all over the country, and not everyone needs to be treated for it. But if they do have risk factors for progression, then there might be a need for intervention.

Host Amber Smith: So who is at risk for a superficial venous disease?

Anderson Anuforo, MD: So I tend to classify this into those with modifiable risk factors and those with non-modifiable risk factors.

The non-modifiable ones, I'll start with that, is age. We cannot turn back the hands of time. Female sex tends to be a slightly higher risk. Family history is something you can't change; sometimes we've seen that people who have family history of these varicose veins and venous issues tend to have it appearing in their children. There are some genetic conditions; the names are not important. There are a bunch of names I could start reeling out now, but basically these names, they affect the structural integrity of the superficial veins, and that increases the risk of people that have those diseases having superficial venous diseases.

But thankfully, there are a number of modifiable ones that people can do things about, things like smoking, prolonged standing, prolonged sitting. If they have certain heart conditions like heart failure, situations like that, treating those underlying issues will also help. Deep venous thrombosis is also modifiable because there's treatment for that. And if you're able to treat that, it might help improve the superficial venous disease. It's also found to be more common in pregnancy, so that's another risk factor.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with Dr. Anderson Anuforo about superficial venous diseases. He's a chief resident in internal medicine at Upstate.

So how are these diseases diagnosed, or how are they recognized? Is it usually a primary care provider that notices it, or do patients experience some symptoms that bring them to a doctor's office?

Anderson Anuforo, MD: That's a great question. There are symptoms associated with it, things like leg swelling, the leg pain. Sometimes you can visibly see the abnormal veins, or you can actually feel it. In cases of, like, blood clots in the superficial veins, you can feel it when you touch it, that this is hard, it's not like a regular vein that collapses.

Some people might also have increased pain in their legs, and then they might complain of that to their primary care provider. So I think a good number of these cases are picked up by primary care providers.

However, in the more advanced stages, then a couple different subspecialties start getting more involved, like vascular surgery, wound care and some portion of interventional cardiology. Some people do superficial interventions, so there is that overlap. So it's multidisciplinary, but primary care does see a significant number of these.

Host Amber Smith: Is there any testing that goes into diagnosing?

Anderson Anuforo, MD: Oh, yes. Oh, yes. So first-line tests would be an ultrasound, basically just a basic ultrasound of the superficial veins, and then checking to see how the blood flow is between the superficial veins and the deep veins, which typically they're connected by what they call the perforator veins. Just imagine a superficial one, a deep one, and then something -- a bridge -- between both of them.

And these are evaluated using ultrasound. And on the ultrasound, you can also check to see flow, and so you can also diagnose something like the chronic venous insufficiency based on the reflux in the veins.

So that's first line. There are some more advanced things (tests) like MRIs and CTs. There's a procedure called plethysmography, which you measure the pressure within the vein. It's more advanced, but first line would be an ultrasound.

Host Amber Smith: Well, let's talk about what treatments are available and how effective they are.

Is there a gradation? Do you start with a certain thing and see if that works and then move on?

Anderson Anuforo, MD: It kind of depends on which of the superficial venous diseases that we're dealing with.

So, like I said, the CEAP, that's the common "clinical, etiological, anatomic and pathophysiology," that's the name of the classification -- based off of that, if it's a varicose vein or a reticular vein (visible but smaller than varicose veins), the more milder, superficial ones, a lot of times topical creams. There are a bunch of creams, azelaic acid, metronidazole cream. There are a couple of creams that work, and you might not need to do any medications or any interventions for that.

From varicose veins onwards, where you have, like, leg ulcers and all of that, there are other treatment options. Some are systemic: We take it like drugs, medications. So if it's like leg swelling, in that case, a water pill that helps people pee can help the swelling resolve.

There are some other, they call it medical foods; the trade name is Vasculera. It contains a flavonoid, which is some kind of chemical that helps improve the structure and the integrity of the vessels. And it can be used primarily or as an adjunct.

And then in patients who have the blood clots in those veins, for those who are at high risk of the blood clot going on to become a deep venous thrombus, a blood clot in the deep veins, or dislodging and going to the lungs, for those patients, there's also a role for using a blood thinner for a short period of time.

So those are a couple of the treatment options, pharmacologically. There are a bunch of newer interventions that are usually within the field of vascular surgery or wound care or interventional cardiology, as well.

Host Amber Smith: Do compression stockings offer any assistance?

Anderson Anuforo, MD: Oh, they definitely do. That's one of the first-line things, in addition to lifestyle modification, so trying to minimize prolonged standing, prolonged sitting, compression stockings are among the first line of things that help with swelling, varicose veins, even, like, venous ulcers. Even at pretty much the last stage, compression stockings are still first-line treatment for a bunch of patients.

Host Amber Smith: Can any of the conditions that we've talked about be reversed with diligent treatment?

Anderson Anuforo, MD: Oh, yes. Oh, yes, especially if it's found earlier. There are a good number of these situations with lifestyle modifications and treatment, you're able to significantly reverse the trend and help prevent newer ones from forming. Because just because it's on one leg doesn't mean it cannot appear on the other one. And so with lifestyle modifications and things like that, compression stockings and adhering to whatever treatment regimen is provided by the providers, that might also help reverse the trend.

Host Amber Smith: So that's encouraging.

Anderson Anuforo, MD: Yes.

Host Amber Smith: You had a paper on this subject published in the Annals of Vascular Surgery Journal, and you mentioned a growing clinical and financial burden of superficial venous diseases. What did you mean by that?

Anderson Anuforo, MD: Not really surprisingly, a good number of these cases are actually undiagnosed, because some people see it on their body, and they never bring it up with their primary care provider, so it's significantly underdiagnosed.

However, for example, like varicose veins, about 150,000 new cases of these are diagnosed every year, and health care costs are close to $500 million every year. And that's just for that.

If we go on to talk about chronic venous insufficiency, like the incompetent veins and how much more it runs into millions and millions of hundreds of millions of dollars, and possibly even into billions of dollars, if we begin to factor in how these diseases affect the lifestyle and the productivity of these individuals.

It can have significant, far-reaching effects.

Host Amber Smith: Do health insurers typically cover care? I mean, if we talk about varicose veins, for instance, is a health insurer going to pay to have someone's veins taken care of?

Anderson Anuforo, MD: So for most of the creams and the medications, oral medications, a good number of that is covered by insurance.

However, when we start getting to the interventional things, a lot of fancy names -- so there are thermal interventions and there are non-thermal.

So thermal, basically they use heat to burn up the veins and then close it up, and then that way it's almost like it gets squished, and it doesn't open up anymore, so blood is forced to go through the veins that work and not through the ones that are incompetent. So endovenous laser ablations, microwave, radio frequency, steam are thermal options. Some of these are not covered, especially by Medicare, so that can be a challenge for the patients.

There are other sclerotherapies where we don't use heat. They use different chemicals that also cause the same, pretty much the same, effect.

And it kind of depends. But there are some of them that are covered by insurance and some are not.

Host Amber Smith: It sounds like there's a lot of options out there and that patients really need someone like yourself to kind of guide them to what would help in their situation.

Anderson Anuforo, MD: Oh, yes. There are a lot of options out there, and thankfully, there's a lot beyond myself; there are a lot more providers, and it's multidisciplinary. A lot of different specialties get to see different people at different stages. like for example, the wound care team also sees some people with advanced ulcers. And there are artificial skin graft substances that are also used in caring for patients with superficial venous diseases.

But there are definitely options and providers out there, unified, willing to help and provide hope to these patients.

Host Amber Smith: Dr. Anuforo, I appreciate you making time for this interview.

Anderson Anuforo, MD: It was my pleasure.

Host Amber Smith: My guest has been Dr. Anderson Anuforo. He's a chief resident in internal medicine at Upstate Medical University.

I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," new insulin delivery options are on the horizon.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

People who have Type 1 diabetes require insulin to keep their blood glucose levels where they need to be to stay healthy. Many with Type 2 diabetes also need insulin therapy. This involves injecting insulin through a syringe or an insulin pen multiple times a day, or using an insulin pump and monitoring glucose levels.

But there are new technologies available and being tested in clinical trials. We'll hear about them from Dr. Ruth Weinstock. She's a distinguished professor of medicine, the chief of endocrinology, diabetes and metabolism at Upstate, and she's past president of medicine and science of the American Diabetes Association.

Welcome back to "HealthLink on Air," Dr. Weinstock.

Ruth Weinstock, MD, PhD: Thank you.

Host Amber Smith: So let's start with some definitions. What is an insulin pump, and how does it work?

Ruth Weinstock, MD, PhD: So an insulin pump is a different way of delivering insulin, instead of giving multiple injections a day, it's a way of giving insulin continuously.

So the pump has a cartridge filled with insulin, and then there's a catheter (hollow tube) that goes from the pump that the individual inserts just under their skin in the fatty tissue, which is the same place where they inject insulin. And that can stay there for three days or even up to a week, depending on the pump that they use. And then the pump infuses small doses of insulin every five minutes.

And the idea of that is to cover the needs of the individual to keep their blood sugar normal when they're not eating. And some people have different needs at different times of the day.

So the nice thing about the pump is it can change the amount it gives, depending on the person's needs. And then when they eat a meal, particularly eating carbohydrates, which turn to sugar and raise your blood sugar after you eat them, it can give what we call a bolus, or more insulin, through that same catheter to cover that rise in blood sugar that happens with the meal.

Host Amber Smith: So the patient doesn't really have to worry about this as much as they used to previously, before they had insulin.

Ruth Weinstock, MD, PhD: Well, it's still a lot of work. The individual still has to look at their blood sugars and still has to decide how much they're going to eat and what's the proper dose of insulin to give to cover that meal.

Now there's also a new technology called continuous glucose monitoring. It's been available now for several years, and that's another small device with a very thin filament that's placed in the arm or on the abdomen, and that measures your glucose or blood sugar levels, also every five minutes. And displays it either on your smartphone or on a reader that you can purchase along with the sensors.

And there are two main ones that are available, Dexcom and Libre, which people may have seen advertised on TV. They're nice because they show what your blood sugars are doing.

Host Amber Smith: Now, what is the difference between a tubeless pump, getting back to insulin pumps, a tubeless pump and other types of pumps?

Ruth Weinstock, MD, PhD: The original pumps and many that are available now, you could wear on your belt or put in your pocket, and then there's a long catheter that is used, the end of which is inserted either in your abdomen, but in the tissue right under the skin, where the insulin gets infused.

Some people, don't like wearing the pump. The tubing might get caught on things, or they may not have pockets in the clothes that they wear ... a variety of reasons.

Many people love these pumps, but there are some people for whom it's problematic. And so there's another pump that's tubeless, and basically what that is, it's a pot, it's a small insulin patch. You fill it with insulin, you apply it to the body. The catheter or needle goes right under the skin, the same place, but there's no tubing. So the insulin, instead of being in a pump that's not on your body, it's actually on your body, and it's controlled by either your smartphone or by a controller, another device that comes with it, so you can control it.

Host Amber Smith: So do these pumps measure blood glucose levels as well?

Ruth Weinstock, MD, PhD: So they don't, but many of them now do communicate with these continuous glucose monitors, and that has been one of the biggest advances for people who need to take multiple daily insulin injections, which is everyone with Type 1 diabetes and many with Type 2 diabetes.

So what we have now is people using a pump and a continuous glucose monitor in what's called a hybrid closed-loop, so there's some automated insulin delivery, and this is a big advance. So the pump receives glucose readings every five minutes and has an algorithm in it, a brain in it, that's very smart and can predict where your blood sugars are going to be in a half hour, depending on what the blood sugar is at that time and how fast it's changing and in what direction it's changing.

And so based on that, it delivers different amounts of insulin every five minutes, so small amounts of insulin. When you use a pump by itself, you program it to give a certain amount of insulin every five minutes. But in these new systems that are receiving this information from the continuous glucose monitors, the pump can make changes in how much insulin you need. So if your blood sugars are going down, it can suspend delivery for a few minutes, it can give less. They're going up, it can give a little bit more. So that really has been a big advance.

And some of the more advanced ones, when you give an insulin bolus for the meal, it can give extra insulin if you under-bolus. If you didn't give quite enough insulin, and your blood sugars are going up, let's say you took another helping or decided to have some dessert, or whatever the issue is, and your blood sugars went a little too high, or you went to a Chinese restaurant and you didn't realize how much sugar was in the food, it can give you some ... what we call correction doses, some extra insulin, to try to keep you at your target.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Ruth Weinstock, the chief of endocrinology, diabetes and metabolism at Upstate, and our subject is insulin delivery.

So these insulin pumps, the tubeless ones particularly, can a person wear that around the clock, when they go swimming, when they're in the shower? Or do they have to come off during those times?

Ruth Weinstock, MD, PhD: So actually all pumps are used around the clock. They have to be, particularly if you have Type 1 diabetes, so everybody wears them 24/7, whether it's tubeless or not. And the communication with the continuous glucose monitors occurs in both the tubeless and the pumps with tubing. So that isn't different.

Now, you can shower with the tubeless one, obviously without taking the device off, but with the ones that have tubing, it's not difficult either because there is a way to detach the catheter from your body for a shower without taking it out of your body. And you can shower, you can swim, and then you can just reconnect afterwards.

Now, the automated insulin delivery that you described, can that be used in people who have trouble remembering to take mealtime insulin injections? That's a great question. What we find is that these devices work best when people do bolus for meals. But even if they forget, they still are helpful. Your blood sugar will not go as high. Your blood sugar control won't be perfect, but I have patients who are using these who have, for example, cognitive impairment and have difficulty remembering how to bolus, or there are some people who just forget sometimes, but at least the pumps will give some correction doses so that it wouldn't be as high as it otherwise would.

They're not perfect yet. However, there are clinical trials now, and there are advances of a total closed-loop system, meaning that you wouldn't have to bolus at all. The pump and sensor do everything for you, and hopefully those systems, with even more sophisticated algorithms, brains, in them will be able to control blood sugars, and the individual won't have to worry about bolusing and greatly decrease the burden of having diabetes.

One of the great things about these automated systems is that they do reduce time that your blood sugar goes too low, hypoglycemia, because it suspends insulin delivery if it senses that you're going to go too low, and people have a much greater time in the normal range.

Host Amber Smith: You keep saying "the bolus"? What is a bolus?

Ruth Weinstock, MD, PhD: The bolus is when you tell the pump to give extra insulin because you're about to eat.

Host Amber Smith: I see.

Ruth Weinstock, MD, PhD: So you can either tell it how much you're going to eat, how many carbohydrates, or if it's a small, medium or large meal, and we program in how much insulin is needed for that.

So bolus is basically extra insulin. The basal (base rate) is the every five minutes to keep you normal when you're not eating.

Host Amber Smith: I see. Can you tell us about inhaled insulin? Does it work as well as the injectable kind?

Ruth Weinstock, MD, PhD: Inhaled insulin has been available for a while. It's a very rapidly acting insulin. So if you have Type 1 diabetes, you still need to take a long-acting insulin if you're using inhaled insulin. So the long-acting insulin, the idea would be, that would keep your blood sugar normal when you're not eating, and the inhaled insulin, you would take when you're about to eat.

It works faster than the injectable insulin and doesn't last quite as long. Some people find it very helpful. It's only available in certain doses, and you can't use it if you have any chronic lung disease or asthma, so there are some restrictions. And some people do develop a cough or wheezing. You have to monitor pulmonary function when you use that.

So there are some limitations. So for some people it works really well, and for others, the injectable works better. But you can't use the automation with that. So that's a way of instead of an injection, for meals.

Host Amber Smith: Well, what about oral insulin?

Are there pills that you can take?

Ruth Weinstock, MD, PhD: Not yet. The absorption of the oral insulin can be erratic. And the dosing is problematic. So, so far, it has not worked as well as injectable or inhaled, and it's not yet commercially available.

Host Amber Smith: Are there transdermal insulins, where it would soak in through the skin?

Ruth Weinstock, MD, PhD: So actually, no. Right now, the only insulins are injectable or the inhaled. Those are the only ones that are available right now. And as I said, the inhaled is only for fast acting, for meals. Or if you are very high, and you want to bring it down quickly.

Host Amber Smith: What clinical trials are you doing with new insulin delivery devices?

Ruth Weinstock, MD, PhD: We do a lot of clinical trials here at Upstate. Actually, we have about 20 research, clinical research, projects related to diabetes, so we're constantly testing new devices, new pumps, where they have improved the technology. They're constantly improving the technology, making the algorithms better so that they correct people's blood sugars more accurately and more automatically.

So we have trials with new devices that are doing that, new insulin pumps. We're also doing a trial with pumps and Type 2 diabetes. So traditionally, insurance has only paid for insulin pump therapy in Type 1 diabetes, but many people with Type 2 diabetes also require insulin therapy. And so we are finishing a trial now, and we have a couple more that we're going to be starting, with Type 2 diabetes using automated insulin delivery, where the individual wears the sensor and the pump. And there's the automation that I talked about, and most people do extremely well, so we're hoping that the results of these clinical trials will make it such that insurers will be willing to pay for this technology in Type 2 diabetes for people who need it.

Host Amber Smith: What new developments are you most excited about?

Ruth Weinstock, MD, PhD: So I'm really excited about the new pumps and sensors and making it totally automated, so the individual doesn't have to do anything. Well, they'll always have to do something, but they put the pump on, they put the sensor on, and then they don't have to think about it. That would greatly reduce the burden and improve blood sugar control for people with diabetes.

But that's not a cure. So there are new approaches that I find extremely exciting that hopefully we will see more in the future. And we are just starting to do research in this area right now at Upstate, which is regenerating islets. So the islets are the part of the pancreas that has the cells that make insulin and control blood sugar.

And there are ways now to take stem cells like from skin cells or other cells, not embryos -- it doesn't have to be embryos, but it could be other cells -- and actually generate new organs and islets. So we are collaborating, with groups and we have investigators here as well who are working on this technology.

So someone with Type 2 diabetes who needs insulin, if we could take some of their skin cells and generate, make islets and give it back to them, that would be a cure, and that would be fantastic.

So all these technologies have reduced the burden and helped people with diabetes avoid complications, but they're not cures.

The cure would be either transplant or actually regenerating islets, but making islets and giving it to people where they don't need to take immunotherapy, immunosuppressants, that's the goal. With transplants now you have to take drugs that have some side effects, potentially.

So if we could make islets that you don't need to take those drugs, that would be just wonderful for people with diabetes.

Host Amber Smith: If you're working from the person's stem cells to create the regenerative islets, would that eliminate the need for medications for anti-rejection?

Ruth Weinstock, MD, PhD: Well, we hope that it can be developed in such a way that that could happen.

There are also people who are looking at encapsulating the islets with substances that have little pores that the insulin and glucose can go in and out of, but the immune system can't attack the islets. So there is a lot of exciting research going on.

We also have clinical trials going on in people with very early-stage Type 1 diabetes, giving treatment that can hopefully prevent the progression.

A lot of exciting trials. If, anyone who's listening is interested in learning about trials, they can give us a call at 315-464-9012, and we can give you more information, or 315-464-9008.

Host Amber Smith: I appreciate you making time for this interview, Dr. Weinstock.

Ruth Weinstock, MD, PhD: Thank you.

Host Amber Smith: My guest has been Dr. Ruth Weinstock. She's a distinguished professor of medicine and the chief of endocrinology, diabetes and metabolism at Upstate, and she's also past president of medicine and science at the American Diabetes Association.

I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from Michelle Caliva from the Upstate New York Poison Center. What are the top five poisonings for all age groups seeking help from the poison center?

Michele Caliva: It has been consistent, if we look at the data for many, many years. It's acetaminophen. It's the active ingredient, for example, in Tylenol -- Tylenol is a brand name -- and for ibuprofen, so Motrin or Advil. We think that that's probably related to the fact that most people have it available and accessible. Acetaminophen is very, very dangerous. It causes death to the liver if it's taken in an overdose, and it really makes people very, very sick. And we see it pretty consistently.

And then bleach is still there as our No. 2. , household products. People are cleaning with bleach. We saw an uptick during COVID; that's continued. Bleach, for example. It's taking your bleach and mixing it with your ammonia because you really, really want to get that bathroom floor clean. And that's a terrible combination. It actually produces chlorine gas, which can make someone have difficulty breathing.

And then our No. 3 was hand sanitizers. Again, I think a throwback to what we were all doing with COVID. So hand sanitizers are 70% alcohol. Really problematic if a little person gets into 70% alcohol. It's actually not good for any of us. But drinking hand sanitizer can lower the blood sugar level in little kids and can make them sick. So that's a problem.

And then we are seeing antidepressants. Very often, it's individuals that maybe have taken too much or have overdosed on their own medications.

And then also some sedatives, so that would be like a benzodiazepine, so people might recognize the name Valium or Ativan. So those were our top five for all age cohorts, so that would be zero to 100.

Host Amber Smith: You've been listening to Michelle Caliva from the Upstate New York Poison Center, which can be reached at 1 800-222-1222.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Renee Emerson is a poet and homeschooling mom of seven. Her most recent book, "Church Ladies," is published by Fernwood Press. Her poem "Room 4" is the perfect example of poetry's ability to compress a story while ever expanding the emotion.

"Room 4"

It's dried, the blood spot high up

on the wall, where the janitor can't reach,

so she asks me if I will wear the rubber gloves;

as she instructs, I scrub.

We were there, a room over, when the emergency

surgery happened, and again, to see the family

lining up at the doorway, a soup kitchen of lasts,

the light from the hallway falling on the heads

of the mother and baby on the hospital bed.

The nurses tell me we are lucky to have this room.

At certain times of day, they say the light seems to hover

above the bed, like an angel, and you can angle

the picture just right to make it look

like there's much more hope than there is.

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": all about menopause.

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 Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.