REFERENCE ARCHIVE

WebMD Live Events Transcript

You have diabetes. Now what? How do you begin to get your condition under control? What should your levels be? What's the best way to test? What about diet and exercise? We asked these questions and more on Sept. 21, 2004, when we welcomed The Cleveland Clinic diabetes expert Byron Hoogwerf, MD, as part of the WebMD University course "Diabetes: Get the Advantage."

The opinions expressed herein are the guests' 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.

Support for this University course was provided by Medical Mutual.

MODERATOR:
Welcome to "Diabetes: Get the Advantage" Your instructor is The Cleveland Clinic diabetes expert Byron Hoogwerf, MD, FACE. Dr. Hoogwerf, what's the first step toward getting control of diabetes?

HOOGWERF:
First, recognize that diabetes is serious and that management is a lifelong process. Then consider day-to-day management of blood sugars. With newly diagnosed people we generally focus on blood sugar first and that focus includes:

A review of diet
A review of exercise
Decisions about whether medications may be needed to help control blood sugar

MEMBER QUESTION:
I was diagnosed with type 2 diabetes in July, my doctor prescribed 2,000 milligrams of Metformin daily and the past week added 8 milligrams of Avandia. Since the Avandia I have became very nauseated and have had vomiting spells along with dizziness and cold sweats. Is this normal? And as my sugar is running between 180 and 300 daily why has my doctor not prescribed insulin?

HOOGWERF:
There are several approaches to managing blood sugars:

At onset, some people can be controlled by diet and exercise only. Most physicians start with a single medication; Metformin, or glucophage, is a common choice. It will often lower blood sugar effectively.
The next steps are to add a second medication if necessary, perhaps a TZD, like Avandia, or Actos, both of which sensitize the body to insulin or make insulin work more efficiently. Another class of agents often added is the sulfonylureas, which stimulate the pancreas to produce insulin.
In some cases, patients with very high blood sugars, for example, over 200 after starting a single medication, will go to insulin.

The judgment about whether to add oral agents is based on:

What your blood sugars are doing
Your personal preferences
Potential side effects of medication

Nausea is actually more commonly seen with Metformin than it is with Avandia. Common side effects with Avandia are weight gain and some swelling in the legs. Any time patients have side effects it is advisable they review their current medications with their treating physician.

"Adding medication over time is a common practice, and I tell patients, if you have diabetes long enough, you are likely to require insulin."

MEMBER QUESTION:
Will you gain weight on these medicines?

HOOGWERF:
If your blood sugars are running very high and you are spilling sugar in your urine, diabetes may start with weight loss. However, as sugar levels come down, especially if you do not decrease calories, you may gain weight with essentially all of the oral medications or insulin. The weight gain is slightly less with Metformin than other medications.

Weight gain appears to be greatest when insulin is used with the TZDs, like Actos or Avandia. For this reason, instruction in proper diet and review of an exercise regimen is part of the initial and ongoing therapy in everyone with diabetes.

MEMBER QUESTION:
How long can it take to even out blood sugar levels?

HOOGWERF:
I don't want this to sound "flip" but consider that it takes a lifetime. Having said that, in patients who have new onset diabetes, it usually takes a matter of several months to bring sugars from values in the range of 200-plus to the more normal range of under 120 or under 130.

The nature of type 2 diabetes is one where there is progressive loss of insulin production over time. Consequently, there is a tendency for sugars to increase over time. That means medication which may control your diabetes now may be insufficient in a few years. So adding medication over time is a common practice, and I tell patients, if you have diabetes long enough, you are likely to require insulin.

Usually diabetes can be controlled early in a few months, but truly it really takes a lifetime of adjusting diet, exercise, and medication to maintain blood sugar.

MEMBER QUESTION:
Is an average reading of 153 blood sugar over three months high?

HOOGWERF:
Yes. I presume you're getting that figure from an average in your glucose monitoring device or through use of the averaging test called a hemoglobin A1C. This test averages your blood sugar over a period of about two months. Both self-monitoring and hemoglobin A1Cs are important in helping to determine proper management strategies for blood sugar.

In people who do not have diabetes, fasting or morning blood sugars typically are in the 80 to 90 range and after a meal; blood sugars rarely go over 150. So an average blood sugar is in the range of 100 and hemoglobin A1C values are often 5. So your blood sugars are clearly moderately elevated, although average for many people in diabetes clinics.

Most people with blood sugars in the 150 range do not have symptoms; however, blood sugars in this range may still be associated with future risk for the complications of diabetes including eye damage (retinopathy), kidney disease, or nephropathy, or nerve damage.

It is still not entirely clear how low we need to get blood sugars to reduce the risk for these complications, although patients with an average of 150 are clearly at lower risk than people that run 200, for example. Most physicians believe that getting sugars as low as possible safely is the correct approach. Sometimes side effects of medications, frequent low blood sugar reactions, or other limitations prevent us from getting sugars into a consistently normal or nondiabetic range.

MEMBER QUESTION:
I am pretty much in control of my type 2 diabetes, testing about 105-120; however there are days when I spike up to about 155. Should I be overly concerned with these spikes, when they happen only about once or twice a month?

HOOGWERF:
Generally no. Spikes can occur because:

Sometimes we inadvertently eat too much.
Stresses may raise blood sugar.
People occasionally forget to take medication.

In general, if most of your blood sugars are in normal or near normal range, don't worry about the occasional spikes in the range you reported.

"Most people with blood sugars in the 150 range do not have symptoms; however, blood sugars in this range may still be associated with future risk for the complications of diabetes."

MEMBER QUESTION:
I am wondering if gestational diabetes is a precursor for diabetes later?

HOOGWERF:
Diabetes in pregnancy or gestational diabetes is, in fact, associated with an increased risk to develop diabetes in the future.

It is not a risk that absolutely predicts that you will have diabetes, but a certain percentage of people with gestational diabetes will develop type 2 diabetes later in life. The risk is highest in certain minority groups, including women of Hispanic background.

Our usual approach to dealing with someone who has had gestational diabetes is to:

Encourage them to keep their weight down
Exercise regularly
Have regular blood sugar screenings, most commonly a fasting blood sugar once a year or so

Occasionally people with gestational diabetes may have intermittent oral glucose tolerance tests. Studies are underway in people who have had gestational diabetes to determine whether certain medications may reduce the risk for future diabetes.

MEMBER QUESTION:
Why does my doctor stress the need not to go too low in blood sugar levels?

HOOGWERF:
An excellent question. The limiting factor for blood sugar control in many people with diabetes is the risk for hypoglycemia (or low sugar reactions). Low sugar reactions generally do not occur in people controlled with diet only, and are rare in people on Metformin or the TZDs.

The sulfonylureas medications, like glyburide, glipizide, or glimepiride, as well as insulin, are associated with an increased risk for low sugar reactions. Mild, low sugar reactions, which can be associated with feeling sweaty, clammy or hungry, are not particularly dangerous and can be treated with glucose tabs or foods that rapidly raise blood sugars.

When blood sugar levels drop into the 50 range or lower, then sometimes the brain doesn't work very well. This may be associated with confusion, difficulty with activities such as driving an automobile, risk for falling, and similar adverse events. Reduce the risk for lows by including frequent blood sugar monitoring and appropriate adjustments in your diet, exercise, and medications.

MEMBER QUESTION:
Can you have an occasional glass of wine while on these medications?

HOOGWERF:
Yes, but there are some cautions about drinking any alcoholic beverage for someone with diabetes. Some of the considerations include:

The "empty" calories of alcohol. If obesity is a problem, this is clearly a consideration.
Some patients with diabetes have elevated triglycerides, one of the blood fats, and it's believed that excess alcohol may raise triglycerides. So we are careful about allowing alcohol in patients who have elevated triglycerides.
Potential adverse effects related to the medication you use and to potential effects on the liver.
Alcohol intake may impair the body's ability to deal with a low sugar reaction. When you have such a reaction, the body turns on some hormones that help raise sugar -- alcohol impairs this response.

So what is safe by way of alcohol intake? We generally recommend an upper limit of no more than one drink per day for women, two drinks per day for men, and any time you drink alcohol it should be in conjunction with having food, to reduce the risk for low sugar reactions. Review how much alcohol is appropriate for you with your physician.

MEMBER QUESTION:
If someone stays in control through diet and exercise (near 100 fbg) how long can the progression of this illness be deferred?

HOOGWERF:
An excellent question, and one where no one is average.

I have patients in my practice who have controlled their diabetes with diet and exercise for nearly two decades. Often the diagnosis was made at a time when they were markedly obese and sedentary and by undertaking rigorous weight loss and exercise programs they have managed their diabetes.

I have patients who have gone from nearly normal blood sugars to requiring several medications, or even insulin, in a matter of a few years. If we look at the average rate of change, the hemoglobin A1C goes up by about 1 percent every three years if patients do not have additional therapy added.

"Any time you drink alcohol it should be in conjunction with having food, to reduce the risk for low sugar reactions."

MEMBER QUESTION:
How many carbs should you have for breakfast, lunch, and dinner respectively?

HOOGWERF:
This is one of the most difficult questions to answer for large groups because of individual preferences for eating, as well as variable recommendations across wide patient populations.

We used to recommend that every patient with diabetes have two-sevenths of their calories for breakfast, two-sevenths for lunch, two-sevenths for dinner, and one-seventh of their calories for a bedtime snack, with carbohydrate, protein, and fat the same for each of those meals. It was a wonderful plan for the nutritionists, but not great for patients.

The more common approach today is to recommend some distribution of calories throughout the day but to allow a lot of patient preference. So if your habit is to eat a modest breakfast, a light lunch and a large evening meal, we try to make sure that your medications will handle the larger meals, avoiding elevations of blood sugar and giving you flexibility.

In general, the amount of carbohydrates you should consume overall is related to:

Whether you are obese and how much weight loss is beneficial
How active you are
What's happening to your blood sugars before and after meals

MEMBER QUESTION:
I am carbohydrate and alcohol sensitive. By switching to high protein, low carbohydrates, and no alcohol and caffeine, I seem to be able to control my diabetes with just diet. Any danger with the low-carb angle?

HOOGWERF:
The issue of low-carbohydrate diets relates to what you are trading for the carbohydrate. If in place of carbohydrate you are using protein and monounsaturated or polyunsaturated fats, then the risk of too much fat is not serious. If a low-carbohydrate diet includes many high-fat foods, then there are concerns about the need to follow LDL cholesterol. Most often, we individualize these decisions because it's becoming clear that low-carb diets do help weight loss in many patients, and weight loss is generally associated with favorable effects on blood sugar, blood pressure, and blood cholesterol.

MEMBER QUESTION:
How concerned should I be with the high-fructose corn syrup in products?

HOOGWERF:
The major concern is the total carbohydrate content more than the nature of the carbohydrate. In the course of reading labels you can consider table sugar versus other sources of sugar, including fructose, as interchangeable.

Where you want sweetening without the calories, sugar substitutes such as NutraSweet work best in cold beverages and cold foods, but not as well for cooking. For baked goods you can try Splenda, for example, which tolerates heat and is calorie-free.

MEMBER QUESTION:
I know it is important to check your feet with diabetes. My feet get numb at times and sore. Should I see a podiatrist?

HOOGWERF:
There are a couple reasons to see a podiatrist:

To make sure your nail care is adequate
To have your feet checked to determine whether footwear, including orthotics devices put in shoes to distribute weight, are necessary

When people lose sensation in their feet, they may develop calluses that would be uncomfortable with normal sensation. These calluses run the risk of breaking down and forming ulcers. Daily self-checks of your feet, regular checks by your physician, and as necessary, checks by a podiatrist, are advisable.

Many makers of tennis shoes put out products that are quite good for people with diabetes. My usual recommendation is get shoes with:

Adequate width (no pointy toes)
Adequate depth
Good, firm support

If you have any numbness or loss of sensation in your feet, wear shoes essentially from the time you get up in the morning to when you go to bed. Shoes will prevent against traumas such as bumping into furniture or small objects that get imbedded in your foot and go unrecognized if you've lost sensation. Reduce the risk for amputation by checking your feet regularly and staying in proper footwear.

"I believe you should seek out an internist with an interest in the management of diabetes. There are...physicians who often develop such interests, but they often have less training than general internists."

MEMBER QUESTION:
I would like to find a doctor who has more than general knowledge of diabetes. Should I look for an internal medicine specialist?

HOOGWERF:
As a diabetes specialist who trained first as an internist, I believe you should seek out an internist with an interest in the management of diabetes. There are family physicians and other physicians who often develop such interests, but they often have less training than general internists.

There are a number of ways to find physicians with an interest in diabetes:

Word of mouth from friends
Contacting local chapters of the American Diabetes Association
Contacting local medical societies who may know a physician's interests

The American Diabetes Association and the American Association of Endocrinologists have good contact information. In fact, on the AACE web site, you can locate physicians with interest in diabetes in most communities around the country.

MODERATOR:
Dr. Hoogwerf, do you have any final words on dealing with a diabetes diagnosis for us?

HOOGWERF:
Remember, diabetes is serious; it is a team effort between you, your physician, your nutritionists and other health care providers, as well as the people in your social structure.

Do not be afraid to let friends and family know that diabetes is part of daily living, and that you hope to be able to incorporate its management into your daily activities in a way that's good for your health and still enjoyable for everyone involved.

MODERATOR:
Thanks to Byron Hoogwerf, MD, FACE, for sharing his expertise with us today.

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