The Doctor is In: Discussing Diabetes -- Brunilda Nazario, MD -- 03/18/03
By Brunilda Nazario
WebMD's own endocrinologist Brunilda Nazario, MD, joined us to answer our members' diabetes questions, from diagnosis to treatment, drugs to pumps.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Hello Dr. Nazario. Welcome back to WebMD Live. Let's get started with questions from the members.
Member: I started on Glucophage about 10 days ago and my blood sugar is still averaging 215-263. If it was going to work, would it be by now?
Nazario: Glucophage is a very good insulin-sensitizing drug. It does sometimes take a few weeks to take effect. As solo therapy it's been shown to decrease hemoglobin HBa1c. It usually is started with meals as a 500 or 850 milligram dose, and it's gradually increased over a few weeks. Although, occasionally, it is given as the XL or XR dose. It can take about two weeks before you see an effect. Typically the first thing that patients notice, especially after starting large doses, is abdominal complaint. So you may see diarrhea.
It's an excellent drug because it not only sensitizes you to the insulin that you have, but it also works on other risk factors associated with diabetes, especially elevated triglycerides. So it may take a while before you see the full effect. In the meantime, you can certainly help sensitize your own body insulin by simple things like exercise, which will help muscles absorb and use more sugars as a source of energy. Now, that exercise does not have to be accompanied by weight loss.
A few things you do need to worry about while on the Glucophage:
Member: It's good to have you here, Dr. Nazario. Many of our diabetes community members have appreciated your input on the message board. One common question for the newly diagnosed is how do I learn to eat now that I know I have diabetes?
Nazario: My first suggestion is that a nutritionist, a certified diabetic educator, be involved in the team of people working with you. This is a lifelong disease. And for the most part, you will be guiding yourself through this with the knowledge they give you. Patience is extremely important because, even long-term diabetics will vow to this, it takes a long time to learn all of the tactics that it takes to deal with your disease.
As far as nutritional requirements, there are certain no-no's in the diabetic diet:
Ultimately, the goal of your nutrition should be to maintain good metabolic control, which are the sugars, and a good cholesterol and fat profile that will help you reduce your risk in the future for heart disease and strokes, as well as decreased salt, decreased blood pressure, and the risk of vascular disease. All of these modifications and your nutrition should also be maintained within a restricted calorie intake to benefit weight loss.
Moderator: There are some great resources on WebMD to help you eat correctly. Check out the recipes.
Member: Can high blood sugar cause bad headaches for a diabetes patient?
Nazario: One of the first symptoms of having elevated sugars is the clouding of your mental activity and thirst and excess urination. One of the reasons patients may seem to develop headaches from high sugar is from the dehydration, so it's very important that patients drink plenty of fluid. To make this a little more complicated, many of the cells in the brain shrink when the blood contains lots of sugars, because brain cells use water as well. The shrinkage of brain cells causes a lot of stress within the tissues in the brain, and that is sensed as head pain/headaches.
Member: Dr. I have syndrome X. What exactly is the difference? Is this a third type of diabetes?
Nazario: Syndrome X is a cluster of risk factors that increase your risk of diabetes and athlerosclerosis. There's almost like a meshing between syndrome X, type 2 diabetes, insulin resistance, and the pre-diabetic state. They all basically start with an insensitivity to insulin, and an impaired fasting glucose.
There are currently five criteria. In order to have the syndrome, you need to fulfill three of these:
It's basically the constellation of these major risk factors that make these particular people susceptible to cardiovascular disease.
Member: I have all of these. My triglycerides have peaked at 3300.
Nazario: For triglycerides that are that high, if you are a female, get off of birth control pills or estrogen, if you are on them. That's one of the biggest culprits in diabetic women with that extreme elevation of triglycerides. That level of triglycerides should have you in the hospital. You need therapy to target multiple things.
The high triglycerides, the severe insulin resistance make you probably the ideal candidate for a class of drugs called Thiazolibion. And that's something you should discuss with your doctor. This type of medication basically works on fat tissue, but also on muscle and liver. It makes those organs sensitive to insulin. So the release of those triglycerides is from the fat. The fat cells are not sensitive to insulin, especially the fat in the abdomen. These types of drugs will improve that. These types of drugs will also help the muscle and liver to use and/or store insulin.
The third thing is, what you have is not that uncommon. As we're seeing an explosion of obesity in this country, we'll next be seeing early heart disease. When we're tying this together we're seeing many people who have what is called metabolic syndrome.
We have a new section on WebMD on the latest research in diabetes. You should go there and look at the issue of free fatty acids in this section. It will help you understand your disease a bit better. I think it's an excellent section.
Member: My son is 12 years old. His morning blood glucose level runs between high 200s to mid-300s. We adjust his dosage to try to bring them down, but it seems if we get a normal reading for morning by 10-10:30am his BGLs are very low. Any suggestions?
Nazario: We need to know what medications he's taking. Does he take insulin at night? Is he complaining of headaches in the morning? Is he hypoglycemic at night? High sugars could be anything. They could be result of insufficient insulin. The insulin taken at night, if he is taking it at night, may be wearing out or it could be that he has something called the somogyi effect, where he's actually bottoming out at night. His body is fighting these low sugars by putting out other hormones to put out other sugars. What you're seeing as a result of these sugars in the morning are the hormones that are combating the low sugars.
Member: He is type 1. He is on Humulin and Humalog. He takes a shot in the morning a shot at supper and a shot at bedtime. His night readings are good. He does complain of headaches but not always in the morning. If I give him more insulin at night then before lunch he is getting too low. I'm so frustrated with this morning reading. Is there something we can do?
Nazario: I would suggest a few things. Presumably he's getting Humalog at night, at bedtime, which is good. Not having all the information, it sounds as though he's taking too much Humalog. If he's on a stable dose, that needs to be adjusted. In other words, if he takes five units, whether five units for five or ten grams of carbs, that needs to be adjusted. If he's on a sliding scale for his Humalog, that needs to be adjusted.
Because he's young, you probably have no idea what his physical activity during the day is -- they tend to be very active -- and his eating habits are unpredictable. I would say the best way to go is to go back to your doctor and discuss insulin-to-carbohydrate ratios. For example, the typical ration is one unit for every 15 grams of carb, if he's very sensitive to insulin. If he's more sensitive to insulin than this, then the ration needs to be increased: one unit of insulin to 30 grams of carbs. If he's not sensitive to insulin, then you increase the insulin for the amount of carbs that he eats; rather than one to 15, maybe two units to 15 grams of carbs.
Now, it's not as easy as I make it sound right now. It does take some teaching to do, but it can be done. And it should lessen the amounts of hyperglycemic episodes and hypoglycemic episodes that he experiences.
Moderator: Members are often confused about the tendency toward high fasting blood sugar readings despite having not eaten anything for several hours. Can you explain "dawn phenomenon"?
Nazario: The high sugars with the dawn phenomenon, is just the opposite of the somogyi. They both result in high sugars. Some individuals are extremely sensitive to hormones that peak just before dawn. The classic hormone is cortizol. Cortizol helps the stressed body. And one of the responses to stress is that the body increases sugars. Now the individual patient may not sense stress as we mean it in the psychological sense, but this is more a bodily function, a complex medical term for stress.
How do we differentiate the two?
Member: What are your feelings on insulin pumps and who should use them?
Nazario: This is my personal opinion. I think it's ideal to use for teenagers, because it gives them an improvement in the quality of life. I assume -- I'm not a diabetic -- but I assume with being a teenager, with all the peer pressures, it must be difficult having good control, meaning checking sugars, eating right, eating when you're supposed to, and taking your insulin. Teenagers are at the phase where they want a bit of independence, and I think the pump gives them this.
Outside of this category, I think treatment needs to be individualized to the patient. It's not for everyone. I've seen both extremes. I've seen patients go on the pump and do excellently, and I've seen patient go on the pump and do worse. Most of these are from patients' efforts, although a few are not. It just so happens, despite efforts put in by the patient, the pump doesn't work.
So the ideal patient is really somebody who has good knowledge of diabetes, someone who is dedicated to controlling this disease, rather than the disease controlling them, and is able to lead a relatively normal lifestyle and is able to work with the pump, rather than the patient who puts on the pump and forgets that he or she has diabetes.
Member: I have a problem with diabetic unawareness. My blood sugar levels get too low before any of the usual symptoms are detected. What can I do to reverse this?
Nazario: Assuming that you mean hypoglycemic unawareness, it is really a significant management problem. There are some studies to suggest that awareness may improve with intensive therapy and normalization of glucoses. The risk of hypoglycemia in these patients are because they cannot mount a counter informed response with other hormones. In these patients the aim should not be normal glucoses and hemoglobin A1c's. This is to avoid the possibility of further hypoglycemia. The therapy is to avoid it.
One of the ways to prevent hypoglycemia is to have small snacks between regular meals. Secondly, a medical alert bracelet should probably be worn, should the person have an episode in public, so that others would be aware. Avoid medications that can cause hypoglycemia, like certain heart drugs called beta-blockers or Propranolol and alcohol. Basically, that's it. Management for frequent feeding and snacks is the basic cornerstone of therapy; assuming that this is not from the lack of other hormones and that it's not a secondary medication and that you don't have liver failure.
Member: Have you found the use of a CPAP machine helpful in lowering morning blood glucose readings in people with sleep apnea?
Nazario: Yes, there are a few small studies that have shown improvement in glycemic control in patients with sleep apnea after the use of CPAP. Now I can't tell you that I understand the reason for it. Possibly the improvement of oxygenation has a metabolic affect that positively affects diabetes. I don't know if that's known. But there have been studies that have shown improvement in diabetic control once the patient has been put on CPAP.
Member: Are there any known long-term effects from metformin?
Nazario: Probably your concerns surround a drug that was taken off the market a few years back. It was a derivative of what metformin is. It was taken off the market because patients had died in a state of excess acids, or acidosis in their body. When this was investigated later, it was found that many of these patients had poor kidney function and poor heart and liver function, and now we know that is known as phenformin. Because of this, we now know that there are absolute contraindications to taking this medication.
I addressed this earlier. If you have an abnormal kidney function, the blood test that is easy to determine that by is plasma creatinin, if it's greater than 1.5 in men or 1.4 in women you must not be on this medication. Now, if you're an elderly patient, creatinin comes from muscle, and if elderly the tendency is to not have as much muscle mass. The elderly must be careful in not putting too much weight in the creatinin. Similarly, patients who have congestive heart failure or liver abnormalities should not take this medication. Long term, I'm not aware that this medication has caused problems. On the contrary, there is some belief that metformin protects the heart.
Member: When doing the fingerstick for testing of blood sugar on my mother I read somewhere that you should test on the side of the tip of the finger for better readings. Is this true or should it only be done on the tip of the fingers?
Nazario: It's not that it's better readings, but it's less sensitive. It's always going to be whole blood. No matter where you prick, you will have whole blood. The blood supply is exactly the same. After a while doing the fingerpricking basically you can become desensitized to it. As long as you get a good drop of blood for your monitor, the readings should be accurate.
Member: Is there anything new on the horizon for diabetics?
Nazario: That's an excellent question to close with. I'll refer you, like I did a previous member, to our new section, which is the latest research in diabetes. It deals with type 1 and 2. There's certainly more going on with the field of type 2 right now and I'm hoping we can update every few months.
What I'm seeing is that patients are becoming brighter and they want this information presented to them in a reader-friendly manner. That's what we tried to come up with. So read it, enjoy it, and if you have any suggestions, you may want to put them up there so that we can present this a little more thoroughly. We'd be happy to take your suggestions. I think you'll enjoy this new section of WebMD.
Moderator: Our thanks to Dr. Nazario, and thank you members for joining us today.
Nazario: Thank you for your questions. This was great!
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