Your Guide to Life With Diabetes-- Richard Guthrie, MD-- 11/05/2003

WebMD Live Events Transcript

Who better to answer your diabetes questions than the co-author of The Diabetes Sourcebook. Our course leader for the WebMD University: "Take Charge of Your Diabetes," Richard Guthrie, MD, joined us to answer questions about a variety of treatment options.

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: Welcome to "Take Charge of Your Diabetes," a WebMD University course. Our instructor today is our course leader Richard Guthrie, MD, co-author of The Diabetes Sourcebook.

Support for this WebMD University course provided by GlaxoSmithKline.

Member question: My burning question is: What are the health effects of diabetes if blood sugars are within normal range through diet and exercise. If no other known effect, why, then is someone with normalized sugars still considered "diabetic?"

Guthrie: Diabetes is a genetic disease basically, so that you do have the disease from the time you're conceived. If you don't do the diet and exercise the blood sugars will go back up. If the blood sugar goes up then complications can occur, such as damage to the blood vessels and the nerves, which can result in:

So the diabetes will never go away, but if you can control it with diet and exercise, you're well off. If you don't, then you need to take medicine. But never give up on the diet and exercise.

Member question: What are the chances of inheriting diabetes?

Guthrie: The chances of inheriting diabetes are about 6% in the general population. It varies some with race and ethnic group; it is lower in Caucasians; it is higher in African-Americans, and especially in Hispanics, Asians, and Native Americans, where it has over twice the prevalence that it does in Caucasians.

If you have a family history or you are obese, or if you have babies that weigh more than 9 pounds, or have had fetal loss, your chances of having diabetes also are much higher.

The real problem in our society today is that diabetes is related to obesity and we are all getting too fat. You can't change your inheritance, but you can reduce your chances of actually getting a high blood sugar by exercising and keeping your weight down.

Member question: Why the higher incidence of type 2 diabetes in African Americans, Asians, Hispanics, and Native Americans?

Guthrie: If I knew the answer to that question, I would probably not be here talking today; I would be in Stockholm getting my Nobel Prize.

We don't know whether it's nature or nurture, but there are differences, genetically, probably, in the races. For example, Caucasians have a much higher prevalence of type 1 diabetes than the other groups, but the other groups have a higher level of type 2, which indicates there is a genetic difference in the groups.

There may also be some environmental factors as well, because even within genetically similar groups, there are differences in prevalence. For example, the Pima Indians in Arizona have a very high prevalence of diabetes, while their cousins across the border in Mexico, who are hard-working farmers, and thin, have a low incidence.

Another example is Korea. The 38th parallel, which divides North and South Korea is, after all, a manmade imaginary line and the genetics of the people in North and South Korea are the same. But there is a lot of diabetes in South Korea, but practically none in North Korea. The difference is the South Koreans have become wealthy, have a sedentary lifestyle, overeat, and are becoming obese. The North Koreans have been suffering famine the last several years and are thin and have very little diabetes.

So while there probably are genetic differences between the various groups of people, there also are important environmental factors that interact with the genetics to cause the differences in diabetes.

Member question: Can a type-2 patient ever expect to be off meds with diet and exercise?

Guthrie: Yes. A type-2 patient can come off medications if they lose weight. It has been estimated that over 80% of people with type 2 diabetes can come off insulin and/or the pills -- all meds -- if they were to lose sufficient weight. Type 1 patients can never come off meds, but type 2 patients can come off meds if they eat properly and lose weight and exercise.

Member question: With a STRONG family history of diabetes (mostly type 2) and leading a healthy lifestyle with good weight control (however, must take low doses of prednisone), are hypoglycemic spells considered an early warning of impending diabetes? (age = 55, female)

Guthrie: Yes, hypoglycemia, or more correctly, reactive hypoglycemia, is an early sign of type 2 diabetes. And if you're having hypoglycemia in spite of taking prednisone, which normally raises blood sugars, this is highly suggestive that you may be developing type 2 diabetes and should probably be monitoring your blood sugars on a regular basis at home.

Member question: I have type 2 diabetes. My new doctor refuses to write for the strips and lancets so that I can monitor my blood sugar. I am almost 75 years old and Medicare will pay for them. Is there any logical explanation for his refusal, or shall I change doctors?

Guthrie: I hate to advise anyone to change doctors, but in this situation I think it is probably the thing to do. Yes, Medicare does pay for strips when written for prescription by the physician, and a physician who refuses to do that is not practicing according to the standards of the American Diabetes Foundation. You need to find a physician who will write prescriptions for strips, because they are expensive and it is very important that you check your blood sugar.

Member question: Can being angry and stressed for many years cause diabetes?

Guthrie: Stress does raise blood sugar, but I doubt that being angry and stressed actually causes diabetes. What stress may do is precipitate the diabetic state in someone who is destined to develop it anyway. Stress causes hormones to be produced. Those hormones raise blood sugar, but if the person does not have the genes for diabetes, the body will compensate by raising the blood insulin level and the person will not develop diabetes. But if they have the genes for diabetes, the pancreas may not be able to compensate for the increased insulin need, and thus diabetes will be precipitated earlier than it might have been if the person were not stressed.

Member question: I have an 8 year old who was diagnosed two years ago. We are using Lantus and Novalog and his A1c is still 10. What do you do when conventional treatment is not working? I am very worried about his long-term health.

Guthrie: Yes, you should be worried. Though we don't try to keep the hemoglobin A1c as low in children as we do in adults, 10 is still too high. Our goal for children is 7.5. You're on one of the best programs. I suspect you just need to increase all of the insulins.

One problem may be that if you're doing carb counting and sliding scales you may be underestimating the insulin, since 60% of protein is changed to carbohydrate and that is not included in the carb counting formula. Since kids eat a high-protein diet to grow, carb counting often underestimates the insulin need.

If you cannot get the blood sugar under control with four shots a day using Novalog and Lantus, the next step would be an insulin pump. Eight year olds can use a pump and many of them do very, very well.

Member question: Can an A1c be too low?

Guthrie: A1c will not go below what is normal. In normal people A1c usually runs between 3.4 and 6.1. You cannot lower the A1c probably lower than 3.4. So no, there is not such a thing as too low, but it probably will not go down, because normal people will have some hemoglobin C in their blood. The lower it is, the fewer or less likelihood of complications.

The current recommendation is to keep it 6.5 or below. I have diabetes, I am on a pump, and my hemoglobin A1c is 5.7. That's not too low.

Member question: I take Diovan for high blood pressure and read that it is also helpful with type 2 diabetes. Is there a benefit from this drug in relation to my blood sugar?

Guthrie: I don't know of any benefit to blood sugar, per se, for Diovan. Diovan is a blood pressure medicine and keeping blood pressure down does help prevent complications of diabetes, particularly in the heart and the kidney. That may be what was referred to. I don't know of any affect directly on blood sugar. The benefit is preventing heart disease, stroke, and kidney failure.

Member question: How much exercise, running, or walking is needed?

Member question: What kind of exercise works best?

Member question: Today I ran and walked for 40 minutes. Is that enough or is more needed?

Guthrie: Exercise is a very important factor for all people with diabetes. The kind of exercise depends upon your age and exercise tolerance. As a good general principle, walking is probably as good as anything else. But walking is more than just walking to the mailbox and back, unless the mailbox is a mile away. Usually we recommend 2 miles per day of walking, which should take about a half to one hour, or the equivalent of 2 miles per day.

If you ride an exercise bicycle or a regular bicycle, you have to ride about 5 to 8 miles to get the same exercise.

For those who maybe can't walk, water exercises are very good. For those who can't get out of the chair, if you do nothing but upper body exercises with your arms, it will help.

What you need to do is to get a good checkup from the doctor to evaluate particularly your heart status and then decide with the doctor and/or an exercise specialist what kind and how much exercise your heart will allow you to do. If you have not been exercising and are thus out of shape, you must start slowly and gradually work up to the full 2 miles per day or equivalent.

Our book, The Diabetes Source Book, has tables in the back that give exercise equivalents and what's recommended.

Member question: After a recent hospital stay I have knots in my stomach where the nurses gave my insulin shots and I am wondering if those will ever go away.

Guthrie: Knots where insulin was given usually indicate that some of the insulin was given into the skin rather than below the skin. Those knots will probably go away in time. There are other kinds of knots that occur as well, but would not have occurred in this instance, because the hospitalization was short term. Long term, giving the insulin in the same spot will cause knots of fat to develop, and those take a long, long time to go away. Yours, from getting a little insulin in the skin, as in this instance, should go away in a few weeks.

Member question: What do you do if you're insulin resistant and type 1?

Guthrie: Insulin resistance is almost always a component of type 2. It is not usually a component of type 1. When it occurs in type 1, a cause needs to be looked for. The most common cause is overeating and obesity and under exercising, the same as for a type 2. If that's the case, get the weight down and the insulin resistance should diminish.

There are other causes of insulin resistance in type 1. One is production of insulin antibodies, which bind the insulin. These can be measured, and if this is the cause, changing the type or kind of insulin or giving some cortisone may reduce the insulin resistance. If none of this works, then you simply have to raise the dose necessary to compensate.

There is no limit on how much insulin anyone can take. I have several obese, type 2 diabetic patients taking over 1,000 units per day. And there are reports of people taking two, three, even 4,000 units per day.

The important thing is keep the blood sugars under control to prevent complications and put no limit on how much insulin it takes to do that.

Member question: Can you tell me why blood sugar levels go up overnight?

Guthrie: The liver is a very important organ in blood sugar control. When we eat we take in more food than we need at that particular moment. We store the extra in fat, muscle, and liver. Between meals sugar is released, primarily by the liver, in order to maintain the blood sugar levels to the brain, since the brain can burn only sugar. During the night the brain needs sugar so the liver puts sugar into the system for the brain.

The problem is, the liver is very dumb. It only does what it's told by the hormones, insulin and cortisone. If there is not enough insulin to tell the liver to shut off, the liver will pour sugar into the blood, even if it's not needed. The liver has no signal, other than insulin, to tell it what to do.

Blood sugars going up during the night indicates that the medicine, either oral or insulin, is either too low or not lasting enough to keep the liver under adequate control. A change in medicine is usually then needed.

Member question: I have been controlling my type 2 with diet, exercise, and medicine. All of a sudden my readings have been high. I have cut back on my carbs, but my morning readings are still extremely high. The rest of the day they are fine. What else can I do besides taking insulin?

Guthrie: I don't know what oral medicines you're on and what the dose is, but you may be able to add additional oral agents or push the doses. The principle here is important. That is, that almost all type 2 diabetics will eventually need insulin. It's estimated that at the time of diagnosis you have already lost 50% of your insulin-producing ability. You continue to lose insulin-producing ability at about 10% to 15% per year. So in three to five years, you will have lost nearly all of your insulin-producing ability, and therefore need insulin.

There are three or four classes of oral hypoglycemic agents. You can take all of them at the same time to maximal dose. So if you are not on all of the three classes of drugs, add a new drug. If you are on all three, but not at max dose, push the dose to max. If this controls your blood sugar during the day, but you go up at night and are high fasting, then the next step is to add Lantus insulin once a day at bedtime.

If you're high during the daytime as well, then there is no alternative but to go to insulin. And we usually recommend Humalog or Novalog with meals and Lantus at bedtime.

It may sound terrible to have to go on insulin, but it's not. With modern insulins and equipment it's nothing to take a shot. So you will find that, in fact, you have more flexibility about your lifestyle and eating with insulin than you do with oral agents, because you can change the insulin much easier with change in diet or lifestyle.

Member question: Earlier you said that 80% of type 2 patients could go off medication if they lost weight. How can that be true if you lose most of your insulin producing capability?

Guthrie: With weight loss you need less insulin. There may come a time when even those 80% may lose enough insulin that they will have to go back on medication. So the coming off medication may not be permanent, but you can remain, perhaps for many years, off the insulin or off the medication before you go back.

When you lose weight you need a lot less insulin, so there is less strain on the pancreas and it will not exhaust itself as fast. So instead of losing 10% to 15% of insulin-producing ability, you may lose only two to five percent per year by weight reduction.

But whatever you have to do to keep the blood sugar controlled, you need to do in order to prevent the complications of diabetes, which is where the costs in both money and human suffering lies. What we know above all today is, the complications are preventable if you control your blood sugar.

Member question: Can you get kidney problems from using glucophage?

Guthrie: Glucophage does not cause kidney problems, but if you get kidney problems from diabetes, hypertension, or any other reason, you should not take glucophage. Glucophage is excreted from the body entirely by the kidney, so if the kidney is not working well, the glucophage remains in the blood, builds up, and can cause a condition called lactic acidosis, which has a 97% mortality rate. So glucophage should never be taken if you have any kidney damage from anything, particularly from the diabetes.

If your serum creatinine is greater than 1.4 for males, or 1.3 for females, you should not take glucophage, but glucophage itself does not damage the kidneys. In fact, if it helps control the blood sugar, it helps prevent damage to the kidneys.

Member question: My doctor has taken me off of meds because my blood sugar hovers around 140 to 160. She says it's not high enough for medication. Does that seem to be correct?

Guthrie: That is, to me, a little bit high, but that's a controversial issue in the diabetes world. The American Diabetes Association says keep the fasting blood sugar below 140 and the after meal blood sugars below 180. The International Diabetes Federation says keep the fasting blood sugar below 100 and the after meals below 135. The American Association of clinical Endocrinologists says keep the fasting below 110, the after meals below 140, and the hemoglobin A1C below 6.5.

If your hemoglobin A1c is running about 6.5 with those blood sugars, then they need to come down. I don't know if you're saying fasting blood sugar or post-meal blood sugar, but either way, in my opinion, they're a little too high.

I would discuss that with the doctor, going over with him or her, the recommendations of the various organizations as to what the standards of diabetes care are nationally, and compare yours to those national standards. If they don't match, then something needs to be done.

Moderator: Do you have any final words for us, Dr. Guthrie, before we wrap up our discussion?

Guthrie: Diabetes is a very common, very serious, and very expensive disease in our society today. It is going up at a very rapid rate. We all need to take steps to prevent it by exercise and diet, and for those of us unfortunate enough to have it, we need to be careful about our control and keep our blood sugars and hemoglobin A1c down, because we can now prevent the complications of the disease. It is the complications that cause the costs in dollars and human suffering. It's therefore tragic that anyone today develops complications.

Get a good education about diabetes, its complications, and the options available, and do your very best to keep the blood sugars under tight control. You will therefore be able to prevent or minimize the complications and life will be longer, better, and I hope for all of you, happier. My best regards to everyone, and good luck.

Moderator: Our thanks to Richard Guthrie, MD, president of Great Plains Diabetes Research Inc. and the director of the Robert L. Jackson Diabetes Research Institute, for being our instructor today. For more information, pick up a copy of The ADA Diabetes Sourcebook.



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