- [Announcer] The region's premier medical information program, Call the Doctor.

(light instrumental music) - Every 23 seconds someone's diagnosed with a form of diabetes.

That's a statistic from the American Diabetes Association.

As common as that is hearing that you or a loved one has diabetes can be scary, but medical professionals are teaching people how to manage different types of the disease.

We'll look into how each is treated and what can happen when it's not.

Learning to Live with Diabetes, on this episode of Call the Doctor.

Hello.

Thanks for joining us.

We are so glad you're with us for this season of Call the Doctor.

Let's get right to tonight's panelists.

I'm really excited for this conversation.

I'd love for each of you to just introduce yourself, tell people who you are and where they can find you.

We'll start with you.

- Yeah.

So my name is Dr. Tapan Buch.

I'm a chief cardiology fellow at the Wright Center for Graduate Medical Education.

We have offices all over Northeast Pennsylvania and, you know, my focus today is to talk with you about something that's very near and dear to me, which is type two diabetes affecting the cardiovascular system and how we can talk about lifestyle, prevention, and hopefully some technologies that we have to kind of circumvent and treat the underlying disease process.

- Great, thank you very much.

Dr. Woloski.

- Hi, I'm Dr. Jason Woloski.

I'm a family physician seeing all ages from cradle to grave down at for Geisinger down in South Wilkes-Barre.

I'm also the associate professor of family medicine for the Geisinger Commonwealth School of Medicine.

- Welcome back.

- Thank you.

- It's nice to have you.

And Dr. Saul.

- I'm Dr. Saul.

Solomon Saul.

I'm also family medicine at Lehigh Valley Health Network in Mountain Top.

And I also see all ages and as family physicians, we are the first line to see diabetes as a disease.

And so we do a lot of education on that and I was hoping to share some of that tonight.

- Great.

I can't wait.

We'll get right to it.

And I also always like to start with a definition of diabetes.

And I know we all know roughly what diabetes is or most people do, but I know that there are different kinds as well.

So if you could give us a good comprehensive definition of what's going on in your body when you have diabetes.

- Yeah, so I, you know, as a specialist, diabetes is very unique and interesting to the cardiovascular disease.

So as far as pure definition, I'll leave it to my colleagues because they're the frontline.

- All right.

- As a primary care.

But I can talk about what happens in the cardiovascular system.

So irrespective of type one or type two diabetes, which, you know, docs will define here.

Diabetes affects the heart in several different ways.

So one you have, one you're, quote on quote a diabetic, which is an A1C more than 6, 6.5% is the typical definition.

What happens?

Well, you start developing plaque at an accelerated pace that plugs up all the plumbing of the heart.

So it plugs it up in the coronary arteries, which line the heart.

It plugs it up in the carotids, in your neck vessels, and it plugs it up in the rest of your body, in your legs, your arms, wherever it could find.

So you start developing symptoms there.

Very atypical symptoms at first.

So you feel, hey, my muscles are a little weaker than usual.

I can't walk as much as I could, or I'm feeling lightheaded just by doing very minimal activity.

What else can happen?

Well, you can take a stroke.

So diabetes can cause plugging leads to lack of blood flow to the brain.

You take a stroke.

Diabetes can lead to your heart pumping less than normal.

So these are all definitions of what happens in the system after you get a formal quote on quote label of a diabetic.

- And I think most people don't, they hear diabetes and might not automatically put cardiovascular issues with that, but it sounds like they they can in some.

Or is it some cases or all cases go hand in hand?

- So once you're a diabetic, your risk of cardiovascular disease accelerates.

You know, the purest will say not everyone gets it.

We're all on a bell curve.

Some people never develop cardiovascular disease.

Those are very rare percentages.

I wouldn't count you in the 1% that doesn't develop anything.

Once you're a diabetic, your risk magnifies exponentially.

I like to tell my patients it's a matter of when.

We wanna control the when and we wanna limit the damage it creates in the long term.

- All right.

We'll get back to all of that Dr. Woloski.

We'll start with maybe some different types before we hopefully get to your situation there.

- Sure.

So at its simplest form, most of us have heard of type one and type two diabetics.

Now I will say over the years it has gotten a little bit more complicated.

We have new categories like latent onset, diabetes of adulthood, and it could kind of mix in there.

But at the simplest level, type one means that your immune system, your body is attacking the pancreas and the insulin that you're trying to make.

And because it's doing that, you just don't have enough insulin.

And hence why most type one diabetics are actually on insulin because the body cannot make enough.

The type two diabetics, it's not necessarily in the beginning that you're not making enough insulin, but it's either that you're not getting that insulin out.

So you have a problem with secretion of the insulin or the insulin you're making, your body isn't sensitive enough to it to actually use it in the way you need to.

Hence why a lot of times if you're diagnosed with type two diabetes, we don't have to jump to insulin because you have the insulin.

We just need to give you medicines to allow your body to use that insulin you're still making in a better way.

- Okay.

And how would those be treated?

How would type one and type two typically be treated?

- So type one, a lot of times it is focused on insulin and that might be insulin injections.

That might be an insulin pump, but really replacing that insulin is the key.

For type two diabetics, we're fortunate now that there's a lot of oral therapies and then if you fail one or two oral therapies, you can go to some injectable forms of medicine.

Some of these injectable forms are a once weekly injection.

So, you know, it takes away that fear of, oh, I have to give myself a needle every day.

And because they're not necessarily insulin, you don't have to worry about a lot of times running around with low blood sugar or having to check your sugar all the time.

Now if you fail several of these therapies, oral therapies, injectable therapies, we still use insulin quite frequently for type two diabetics.

But the answer is there's a lot more room and there's a lot more meds in the last 5-10 years than we ever had at our disposal.

So the theory that, oh, now I'm diabetic, I have to be on insulin, is actually not the case anymore.

- Let's take it back even a little bit further.

Can you have diabetes and not know it Dr. Saul?

- Sure.

You know, diabetes is, well there's two types, like Dr. Woloski was saying, type one is pretty obvious when it's gonna be onset because the pancreas is not making insulin.

It happens pretty suddenly.

So the sugars will spike and the symptoms will be pretty will come on suddenly.

Type two is more insidious and it takes a longer time to happen and it's usually caused by obesity and poor diet.

And what happens is that there's a high circulating sugar because of what people are ingesting.

And then that causes there to be an insulin level that goes up that lasts for a long period of time.

And eventually what happens is the body becomes insensitive to the insulin in type two diabetes.

And so then the cells are not really taking the sugar in and then the sugar starts staying in the bloodstream.

Now what happens is, at first you won't get the typical symptoms of diabetes where, you know, they'll get neuropathy where there's tingling in the fingers and hands or vision changes.

That takes a little longer for the sugar to be high in the blood.

But what will happen if the sugar is really high is your body will try to get rid of it by urinating it out.

And so what happens is patients will typically start realizing, "Hey, I'm running to the bathroom a lot, I'm really thirsty."

They may even lose weight sometimes.

And that's usually indicating that your body's just trying to get rid of the excess sugar.

Now if the sugar stays high for a period of time, then people will start getting the damage to the microvascular and then maybe larger vessels later.

But the microvascular is where small vessels can be damaged and that's why they'll get tingling in the feet, tingling sometimes in the eyes.

And also it attacks the kidneys and diabetes is the number one cause of kidney failure.

So it really attacks every part of the body.

But in the beginning it won't be felt until it's a kind of more advanced unless you have these, you know, like the urinating, et cetera.

- So the thirst and the urination, you would say those are two of some of the most obvious symptoms that people might see first?

Are there some others?

You mentioned the tingling.

Is there anything else that I'm missing?

- You know those are the main ones.

There's more, you know, you don't want your first occurrence to be a heart attack or a stroke or anything like that.

But that takes, you know, a pretty, a long time to have damage like that, you know, so those are the main ones.

Polyuria, polydipsia, it's called.

Those are the most common first manifestations of it.

- You mentioned the immune system, Dr. Woloski, is this an immune disorder?

Is it an autoimmune disease?

- So in type one it tends to be where you actually form antibodies that are attacking the pancreatic beta cells that are actually making the insulin.

Type two, it's probably, you know, a mix of things.

You know, it could be your diet, it could be your lifestyle.

We think there's probably some genetic basis, but although those are probably complex and polygenetic and multiple genes affecting your risk for type two diabetes.

So I think it's a little bit of both.

But you know, I think you brought up a great point when you said, you know, recognizing symptoms and I think that's why, you know, from a family medicine standpoint, prevention is key.

And we have this category now called pre-diabetes where your sugar's high, higher than normal, but not high enough to be classified as diabetes.

And in fact, one in three Americans are estimated to be pre-diabetic.

Many as you mentioned probably don't even know.

So if there's four of us sitting here, statistically one of us is pre-diabetic.

And so how do we change our lifestyle?

How do we change the way we're living, the things we're eating to actually make sure we don't become diabetic and have some of the symptoms and consequences that were mentioned here.

- If you do have diabetes other than heart issues, and I know we're gonna get into that a little bit more, but other than cardiac, what other issues, or, I don't wanna say symptoms, but what else would you have to be monitored for?

Are you at higher risk for other things then if you have diabetes?

- Oh, absolutely.

Your eyes should be checked.

Okay.

Blindness due to undiagnosed diabetes is a, you know, unfortunately it's a serious problem.

We want to catch it before that happens, that you start to lose your vision.

- Wow.

- You know, a very symptom that a lot of people overlook is having problems with erectile dysfunction.

That's something that a lot of people overlook, but that's a serious complication or it's, a stage of diabetes we just kind of miss.

You know, other than the heart, strokes, walking difficulties, a lot of problems with numbness and tingling in the feet and the hands.

So you have walking disturbance you just don't know why you can't feel the bottom of your foot.

Next thing you know, you have a cut and you never even realized you had a cut on your foot or on on your hand.

- So it gets that numb and.

- It gets that numb.

Yep.

But that, those are all end stage.

We wanna prevent it before it even gets to that point.

- So I know a fair amount of people who have diabetes, various types, some have the pumps, you know, some are in support groups.

What would your message be to people who have it and, you know, I don't wanna say suffering through it, but this is a lifelong thing, so this is something that they're gonna have to learn to live with.

What is your first out of the gate, your first advice when you diagnose someone?

- Yeah, I think, you know, one of my, you know, biggest advice to patients diagnosed with diabetes is that we can manage this.

This is manageable.

This is not something that I have to sit you in front of me today and say, oh my goodness, you have this process going on and there's nothing I can do.

Those are the worst conversations to have.

But we're fortunate with diabetes that this is a manageable thing.

So I think it's a team approach and, you know, different clinics use different models, but we engage our pharmacy colleagues, we engage our nutrition colleagues.

You mentioned support groups.

I think that's great.

Learning, sometimes just talking about, hey, what do you eat for breakfast?

Because every time I eat breakfast, my sugar goes through the roof and maybe I could learn from you how to make sure my sugar doesn't go through the roof is a great thing that a support group may offer.

So I think the more you can engage this as a team approach and not be afraid of it, but actually embrace it in the sense that I have this now I want to control it, the better outcomes you're gonna have.

- So you'd call it preventable, or at least when I say it, I know there are different types and we need to keep that in mind, but are some types of it preventable?

- Well, I think if you have the diagnosis, I would change the conversation to manageable and treatable rather than preventable.

- And you mentioned, I was kind of surprised when you said this that you can actually reverse some of the progression of diabetes.

Talk a little bit about that Dr. Saul.

- Yeah, so actually diabetes itself is reversible in patients who take aggressive measures to change their diet.

And so if your sugar comes down and your insulin level drops, cause it doesn't need to support that amount of sugar, then your body may start acting normal again, especially if it hasn't been going on for a very long time.

So aggressive diet changes can definitely reverse it, not in everyone, and we're not talking about type one, we're talking about type two diabetics, you know, type one they're body's attacked it and they have to be on lifelong insulin.

So the first thing is, you know, we talk about if a patient comes in with a new diagnosis of diabetes, what's your diet like?

You know, if you're, if somebody's drinking iced tea and soda all the time and they have a poor diet, then starting them on the first line medication and changing that diet can often bring that sugar level down.

Now once that sugar level is down and normal like everybody else, if your sugar's normal, even if you still have the diabetes, your body's not gonna be damaged in the same way as somebody whose sugars are high.

So if really you could control your sugars and bring 'em down, then you've basically, you have the same, you know, you're not gonna be damaged by it really.

- You mentioned the aggressive diet, are you talking about sugar only or are there other things that are part of that diet?

- Yeah, yeah.

So we're starting to kind of change the way we think about diet and what causes sugars to rise.

And refined sugars now are, sorry, refined carbohydrates now, we're starting to realize they convert quickly into sugars and they raise your insulin and lead more to diabetes, to high sugars that cause those outcomes.

So I try to push more for like complex sugars, complex carbohydrates, like whole grains.

And then protein takes longer to break down as as well.

So, you know, we used to think it was, we were pushing for a lot of like white bread and now we're realizing that maybe that's not as good.

But definitely sugars like regular soda and candy, those are just, you're taking them in and they're turning into sugar right away.

- I'd like too to bring up gestational diabetes, which I am not sure, I mean, I know it's a type of diabetes and possibly not, you know, no OBGYNs on the panel here, but when someone comes to you with gestational diabetes, what do you look for?

Or do they now have a higher risk after they've had the baby?

- Yeah, it's a great question.

And I mean, we're fortunate now that most women who are actually getting very routine prenatal care screening for gestational diabetes is common in all women.

So a lot of times, you know, even if you don't have those risk factors, you will still be screened.

A lot of times it's done with a different test called an oral glucose tolerance test where you kind of consume a sugary drink and then they watch how high your sugar goes after an hour or two hours.

But the other thing about gestational diabetes is that in some cases, lifestyle changes as we heard here, can also be successful in that sense.

So just because you're diagnosed with gestational diabetes doesn't mean you have to be on insulin.

Now some women are, but you also have some oral therapy options for gestational diabetes, which we didn't have in the past.

The thing to remember though is that, you know, some people think, okay, well then after I deliver the baby, the pregnancy's over, my diabetes is gone.

And in a lot of case that is true that the diabetes does go away after the delivery, but you still, those individuals in particular are very high risk to developing type two diabetes in the future.

So those are individuals who may wanna make sure that they have that good relationship even after the baby's born with their primary care doc to make sure they're screened, to make sure they're eating correctly, to make sure that they're getting 150 minutes of exercise per week because those individuals are gonna be higher risk for developing full-blown type two diabetes in the future.

- [Host] Is there a genetic component to this?

- Absolutely.

So type one diabetics are, you know, there's a lot of studies going on.

You know, a lot of our diseases that are chronic, what we call chronic diseases and type two diabetes falls in chronic care management.

We're now learning that diabetes has genes associated with it.

And the research is ongoing in this field of what patients are more prone to developing diabetes at what age, as a newborn, later on in their life, even though they do everything right lifestyle wise.

So this is a big area of research, and not only that, but there's researchers looking into what drugs are most effective for specific diabetics.

So are they gonna be more tailored to certain classes of diabetic medications that we have as opposed to others?

What we know is that genetics plays a big role in being at risk for diabetes.

And we, that's why we always ask in our offices, "Hey, your family history, who has diabetes in your family?

Does anyone?"

And that gives us a big clue that you're prone.

- How close of a familial relationship does it have to be to count?

Anybody in your family?

- I think first degree relatives definitely, you know, are some of the highest risks for you.

So, you know, if mom had it, dad had it, a sibling had it, but, you know, I wouldn't rule out that, you know, some grandparents with a very strong family history or something like that.

Now if your, you know, second cousin had diabetes, I don't know how much I would weigh that into, you know, your genetic risk, but definitely first degree relatives, it's very important.

- I would say that, you know, this is not something where like colon cancer or certain types of breast cancer where we're looking at the family history and saying, "Hey, we're gonna start screening you for diabetes because your family history."

This is routine.

If you're seen yearly at least by your primary care doctor, we're gonna get labs or we're gonna see how you're doing, we're gonna see your weight, we're gonna talk to you about your symptoms.

And this is not a diagnosis that should be missed.

You know?

If somebody's overweight and they say, I'm urinating, like I was talking about before, or even if they're not, even if they're not having those symptoms, we will do a fasting blood sugar, and if it's high, that gives us a clue that maybe something's going on here that you're sugar shouldn't be high when you're fasting.

And that'll help us pick it up early and then maybe you have a diagnosis of pre-diabetes.

Okay, now I can educate you.

Let's change your diet before this progresses.

So this is something that's a routine and we're all aware of it in primary care setting and it shouldn't be missed.

The ones who are coming in with really high sugars are people that just don't see a doctor often or never and their first symptoms is showing up in the emergency room.

- Can I touch on one-- - Absolutely.

- Fact that Dr. Saul and Dr. Woloski said, you know, the most important thing that we, you know, we've defined diabetes for you and everything.

We have medications in our tool chest to help you control this disease process that's a lifelong battle once you're diagnosed.

Our role as physicians is to help you prevent to even become a diabetic.

So how do we do that?

The docs have talked about it.

Nutrition is the key.

Green leafy vegetables, avoid the simple carbohydrates, complex carbohydrates.

Exercise daily.

We've touched on 150 minutes of moderate exertion a week.

If you do strenuous, you like to run 75 minutes of that a week, lower your stress level.

There's a lot of hormonal impact on stress.

A lot of people have stress that we don't talk about, that we don't deal with.

Talk to someone about it.

Lower that stress level in your life.

Find coping mechanisms for that.

We can help you sleep.

You need to sleep, you shouldn't just run around with one hour of sleep, two hours of sleep.

Please get that seven, eight hours of sleep.

And lastly, avoid those high-risk behaviors.

Okay, if you wanna have fun, you're going out with friends, you're going out with family and you like to have alcohol, you know, make it so it's not, have a club soda with it, don't make it a sugary drink.

You know, a lot of the drinks that we have have a ton of sugar in them.

Those are very unhealthy for us.

So, you know, nutrition, lifestyle is the most important impact that we can have and preach to our patients to, you know, hopefully avoid even becoming diabetic.

- So if I'm the one out of the four of us that's pre-diabetic in our example here, and I can live a healthy lifestyle, that meditation, lowering that stress, the good nutrition, there's a chance I can prevent that from happening or I will almost certainly prevent that from happening?

- Absolutely.

Our goal if you're a pre-diabetic is for you to never cross that threshold of 6.5% A1C.

We will help you with all we can by encouraging you to never cross that threshold.

So if you live the lifestyle you're living, you're doing all the, you're having a great nutrition, like I said, you're stress level is down, you're exercising, you've lost the weight, your BMI, you're not under the obese category.

That's all we can do.

We can give ourselves the best chance at not developing it.

- We talked a little bit about some new medicines or is there any other new research that's going on right now that you'd like me to know about or new drugs that are out?

Anything for people who have diabetes and they're already in this, you know, is there anything to look forward to?

What's coming up next?

- Well I think we mentioned some of the injectable medicines and I think one of the things that I also like to mention about the injectables is that sometimes you're actually getting almost like a triple bang for your buck.

And what I mean by that is some of these injectable medicines are not only treating your sugar, but they can actually help you with weight loss.

In fact, off-label, some of these diabetes drugs are actually being used only for weight loss.

And the other thing as our cardiologist would, you know, mention is they can actually provide some cardiovascular benefits.

So just by taking this drug, I could be helping my diabetes, potentially losing some weight, and protecting my heart at the same time, which is pretty amazing.

One of the studies that recently came out that many viewers may have seen is focused on this vitamin D supplementation help prevent pre-diabetics from becoming diabetic.

And I will say, you know, in general, vitamin D is a fat soluble vitamin and it's rare to have toxicity, but I wouldn't recommend that everyone run to their, you know, supermarket and start consuming high levels of vitamin D because as we talked about today, there's so many other factors, genetics, lifestyle, you know, other things that play a role.

I think if you have very low vitamin D and your physician wants to help you get that back up, that's one thing.

But I think right now the data's still a little bit limited that I wouldn't recommend, especially since you can have side effects from too much, running to the store and taking high doses vitamin D every day.

- But your key there was that if you talk to your doctor and your doctor suggests x, y, z.

- Absolutely.

Absolutely.

- Are you having, I mean, you must be having those types of conversations with your patients every day about their lifestyle and how to prevent something like this, how to treat something like this.

Anecdotally, what do you hear from your patients?

Are they living okay lives with diabetes?

I mean I've heard stories all across the board.

- Sure.

So definitely in the last couple years we've had better technology and better newer medications that really make somebody's life a lot with diabetes a lot easier.

So there's different medications we were talking about that are injectable that help you urinate out sugar now or increase the, you know, increase your insulin that comes out and decreases your appetite.

And there's several classes of medications that are really helpful and they protect your kidneys, they protect your heart.

There's a lot of research that's showing that you should be on these.

But in addition, we also have guidelines now that help prevent problems that somebody maybe with poorly controlled diabetes wouldn't be able to lead a normal life.

They'd have, you know, bad outcomes with their kidneys and may have to go on dialysis or have amputation, anything like that.

But now with medications like ACE inhibitors for your blood pressure that's shown to protect your kidneys and, you know, taking a cholesterol medicine, a statin has been shown, everybody who has diabetes really should be on that medicine.

That's been shown to prevent strokes and heart attacks.

And so now that we know this information, it can really help prevent the bad outcomes, you know?

This really happened with the heart attacks as well, used to be that many years ago a lot of people in the 50s there were just, every week there were people coming in with heart attacks and then we found out, you know, smoking causes that and using cholesterol medicine to prevents it and now there's a lot less people come to that.

So it's just like that with diabetes now.

And we're learning a lot more.

- I know we have only scratched the surface of this topic, which is a very huge topic, but I thank you for coming onto at least help us with some information.

That's gonna do it for this episode of Call the Doctor.

We're glad you've joined us and for all of us here at WVIA, we'll see you next time.

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