Diabetes Alert Day

WebMD Live Events Transcript

According to the American Diabetes Association, 18.2 million people in America have diabetes. But 5.2 million of them have yet to be diagnosed because diabetes is a silent disease. Could you be one of them? Diabetes Alert Day is a call to action you can't afford to ignore. Brunilda Nazario, MD, joined us on March 22 to answer your questions.

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.

MODERATOR:
Welcome to WebMD Live, Dr. Nazario. Thank you for joining us today. It's Diabetes Alert Day. If there was only one thing you wanted everyone to know about diabetes, what would it be?

NAZARIO:
One thing we should all know about diabetes is a little care goes a long way. The small steps we take today make huge steps in the quality of our life tomorrow, especially when it comes to diabetes.

MEMBER QUESTION:
My brother has diabetes and apparently had it for many years without knowing it. My mom had diabetes too. She was on dialysis for 2 years, taking insulin as needed and just passed away suddenly. My brother is 52 years old, has already had a four-way bypass, is having multiple surgeries on blocked arteries in the legs and the carotid artery is blocked too. What should I be doing besides buying life insurance since I am a single 49-year-old mother of a 9-year-old?

NAZARIO:
The last current estimates hold there are 18 million people diagnosed with diabetes. There are about 5.2 million who have diabetes and don't know it. So what you described is very common, especially with type 2 diabetes. It is a chronic disease which comes on slowly. Many times the complications of the disease such as nerve damage, eye problems, kidney problems or even heart complications are diagnosed prior to someone suspecting diabetes as the cause.

In order to prevent the complications, you should be screened for diabetes. You have a strong family history of the disease and you should look at other risk factors including your physical activity level, whether you're in a high-risk ethnic group, whether you are overweight or obese, etc. A screening test is something as simple as a fasting blood test done in the lab. If it's elevated, meaning more than 126, you have diabetes. If it's greater than 100, you have an impaired fasting glucose otherwise known as prediabetes, which puts you at a very high risk of developing diabetes.

There are steps you can take to prevent the transition from prediabetes to diabetes. Look at the risk factors that you have and which ones can be modified. In other words, if you are an inactive person, work out a schedule of regular exercise. That will help reduce your weight, improve your body's use of glucose and insulin, improve your heart risk factors, and reduce your risk of diabetes and ultimately the consequences of the disease.

"People with type 2 diabetes are usually diagnosed in the physician's office and in hindsight because many complications of the disease can be explained by having diabetes years before that visit."

MEMBER QUESTION:
What are some of the symptoms of the onset of diabetes?

NAZARIO:
It really depends on whether you're talking about type 1 or type 2 diabetes. Type 1 comes on quite gradually and it typically comes on in the older, overweight and sedentary individual. With the increase in childhood obesity, what's happening is we're seeing type 2 diabetes at earlier and earlier ages. The symptoms can be gradual. They can present as complications, either eye, kidney, heart problems or they can present as the sugars increase, to a point where you get excess urination, dehydration, thirst, headaches, blurred vision, and numbness in the hands and feet. Men can have symptoms of sexual dysfunction or impotency, etc.

In type 1 diabetes, symptoms tend to come on more suddenly. Type 1 diabetes is a totally different disease. Here the body does not make insulin. The pancreas -- the organ which produces insulin -- is attacked and destroyed. It results in a deficiency of insulin and more abrupt symptoms. Without insulin, blood sugars progressively increase, you develop symptoms of excess urination, thirst, dehydration, and headaches. Because the body uses sugars as a source of energy, without insulin the body now needs to use something else, so it starts to break down fats or something called ketones. Those ketones build up in the body and can produce a life-threatening situation, which is known as ketoacidosis.

People with type 1 diabetes are usually diagnosed acutely. They come to the emergency room dehydrated and are usually diagnosed with type 1 diabetes in this acute, life-threatening situation. People with type 2 diabetes are usually diagnosed in the physician's office and in hindsight because many complications of the disease can be explained by having diabetes years before that visit.

MEMBER QUESTION:
I started on insulin two weeks ago because I measured a 14 on the A1c, with meter readings too high to record (> 500). The dosage given to me was 70/30 insulin, 20 units before breakfast, 10 units before dinner. This brought the meter readings down to the mid- 200 to high 300 range. But that's as far as the readings will drop. I have experimented with larger doses and am now up to 40 in the morning and 20 at night. But it makes absolutely no difference, the readings are stalled. I've tried fasting for 4-5 hours after a shot and the glucose readings bounced up into the 400s. Yes, I should talk to my doctor but that's expensive on my limited income. I just need to know at what point it becomes obvious that insulin won't work for me. I don't want to keep adding more if nothing will come of it. Is insulin the end of the line for me when it comes to treatment?

NAZARIO:
We can try and briefly answer your question, but it's clearly more complicated than it seems. You've just recently started insulin and there's a lot of information you have not given me, such as if you were on pills before, when you were diagnosed with diabetes, whether you are overweight and obese and what your age is.

Older individuals need to be more careful with insulin. You need to know more about insulin; 70/30 means that there is a premixed insulin with 70% NPH, 30% regular insulin, or a combination of a long-acting and a short-acting insulin. The formula given for insulin is 2/3 in the morning, 1/3 in the evening. We look to see what happens in the blood sugars when giving insulin and after a period of three to 40 days I tend to make a readjustment; you started out at a small dose of 20 and 10.

I don't know if you're taking other medications in combination with insulin. There is a formula for how much insulin the body requires based on your weight. The more you weigh the more insulin your body requires per kilo. What you've changed your formula to is now a doubling of your dose, so 40 in the morning, 20 in the evening is nothing close to what the body does.

I would advise that the best action for you at this point is to speak with a diabetic educator who can teach you about the different types of insulin and how they work and how to adjust them, as well as when to adjust them because sometimes an adjustment may be from dinner to bedtime is all that's needed. Sometimes a change in the insulin is all that's needed and sometimes a boost in the dose is all that's needed. But every patient is different, and not having information on your particular case, it would be difficult to say what you, in particular, should do.

My advice would be to see a diabetic educator who's typically less costly to see yet more informative many times than a physician. Or, many local hospitals or community centers have diabetes education programs which are free. Participate in those. Those will help you get a better grasp of how to manage your diabetes, because ultimately your management of diabetes is what determines success and will reduce your risk of complications in the future.

"Remember, when a diabetic patient is placed on an antidepressant, medications need to be chosen cautiously. A few of these medications can alter blood sugars and cholesterol levels, so it's always a good idea to discuss these with your health care provider."

MEMBER QUESTION:
Will antidepressants help with blood sugar control since stress can raise it?

NAZARIO:
Stress most definitely can increase a person's blood sugar. Stress can be in the form of emotional stress or physical stress, like undergoing surgery or an infection. What stress does to the body is that it increases the levels of certain hormones and in a nutshell, these hormones counter-react to what insulin is trying to do. These hormones tend to increase sugar as a mode of survival during a period of stress. We see it all the time.

The classic example is the patient that comes in whose sugars are always controlled: The perfect patient -- exercising, eating right and has a hemoglobin A1c that is consistently stable. But suddenly the sugars are going up and we can't attribute it to anything. They're taking their medications, following their diet, and their medications aren't expired. Then we talk about some of the social and psychological issues the patient is undergoing, and we find out the social things which affect the patient and that translates into a stress reaction that can increase blood sugars. This reaction is not something you only see with blood sugars. We see that stress can increase blood pressure, and occasionally -- in the extreme -- can cause chest pain.

To answer the second part of the question, can antidepressants help control sugars in a person who's depressed -- certainly antidepressants work to improve the quality of life in someone who suffers from depression. Antidepressant medications, in combination with psychotherapy, can benefit anyone suffering from this condition. Whether this can improve sugars is hard to say. If the stress is the cause of the elevated sugars, I would have no doubt that antidepressants would help. But ultimately we're not treating high sugars with antidepressants -- we're treating depression with antidepressants.

Remember, when a diabetic patient is placed on an antidepressant, medications need to be chosen cautiously. A few of these medications can alter blood sugars and cholesterol levels, so it's always a good idea to discuss these with your health care provider. If you suffer from depression, it is an illness like any other and not a sign of weakness. Get treatment.

MEMBER QUESTION:
What is the maximum amount of times a person should test their sugars in a day?

NAZARIO:
Every case is different. The recommendations are two to three times a day, although people on insulin, people on insulin pumps or people with brittle diabetes are often advised to check their sugars more frequently. Blood sugars fluctuate throughout the day, and although the strips are quite costly, checking sugars once a day or once every few days gains very, very little information.

Ultimately, we know having your blood sugar under control reduces your risk of complications. The only way to know whether your sugars are under control on a day-to-day basis is to check your blood sugars. The more frequently you check the more accurate that information is in reflecting your blood sugar over a 24-hour period.

QUESTION

Diabetes is defined best as... See Answer

MEMBER QUESTION:
I'm a 59-year-old male. I was recently "blood screened" and found to have a fasting blood sugar count of 114. My 87-year-old mother is taking pills for diabetes. I'm about 5'11" and weigh 200 pounds. I've since become more dedicated to my workout program. I weight train three times a week, and do bicycle cardio three times a week. I'm a truck driver and spend most of my time sitting still, looking out the window, but it's interspersed with pretty heavy work. I eat a lot of chicken, fish, and some beef. I eat lots of veggies and fruits, and occasional nuts. I drink red wine with dinner (about a glass to a glass and a half). I don't smoke. I'm going in for a follow-up blood test in about a week. Do I sound like I'm on the right track with my diet and exercise program?

"As you may be aware, one of the biggest complications affecting people with type 2 diabetes is heart disease or premature heart disease."

NAZARIO:
You sound like the ideal patient. At 5'11' and 200 pounds, your BMI (body-mass index) is 28; so you're about 20 percent overweight. But it sounds like you're doing all the right things.

Your fasting sugar at 114 puts you at high risk of developing type 1 diabetes. You're overweight, you have a family history and you have a sedentary type of job; you have a lot of risk factors that would push you towards developing type 2 diabetes. Having prediabetes does not necessarily commit you to having diabetes. I believe the estimates are about 30% of people go on to develop type 2 diabetes, but you have numerous risk factors that push you to a high likelihood of being one of those 30%.

It sounds like you're working on what we call modifiable risk factors -- your weight, your sedentary lifestyle and your diet. You can't change your family history, but the things you can change you are working at. The moderate amount of alcohol is what is recommended by the American Heart Association. At 5'11", ideally your weight should be under 178 to be normal. Dieting and exercise are both the way to get there. Dieting will help you lose weight, which will help improve the resistance to insulin that you have, the exercise will help that as well, but the exercise has the added benefit of being heart protective. As you may be aware, one of the biggest complications affecting people with type 2 diabetes is heart disease or premature heart disease. People who have prediabetes also have an increased risk of heart disease above the normal population, so it sounds like you're on the right track.

MEMBER QUESTION:
Does vitamin C help lower the blood sugar or just mask it?

NAZARIO:
Although vitamin C is an antioxidant, I'm not aware of any good, quality studies that show that vitamin C lowers your blood sugar. Having said that, I do know that vitamin C does interfere with the reading of blood sugars; specifically it interferes with the blood glucose strips.

So, if you're seeing an improvement in your sugars and you are taking vitamin C, make sure this is not a false improvement based on some interaction of vitamin C with the blood glucose strip. Verify it with the three-month hemoglobin A1c reading as well. It may not be the vitamin C; it may be an overall improvement in your lifestyle. I generally see people who take antioxidants who also seem to participate in other healthy lifestyle habits, and that may be what you're seeing in the improvement in blood sugars.

MEMBER QUESTION:
I'm a newly-diagnosed type 2 49-year-old female. At this point I am controlling my sugar with diet and exercise. In the last month my sugars have been a bit high at bedtime: 140 and 155. I go back to see my doctor in April. At what point would my doctor put me on medication?

NAZARIO:
Every patient is different; every doctor is also different. I tend to be fairly aggressive in treating diabetes -- I don't put everyone on insulin. What I mean is that I tend to sit and spend time with patients and really teach them about diabetes and let them know they can truly get a handle on their diabetes if they participate.

If your blood sugar by monitor is 140 to 155, there's a bit of bad news to that. Blood sugar readings on the monitors tend to be lower than what we will get in the lab. The reason for that is that the monitors check whole blood, or the red stuff you see. Blood sugars are actually in the serum and that's what the lab checks. So the blood test will probably come up 5% to 10% higher. To be certain, the doctor will probably order a hemoglobin A1c.

If you're seeing your highest blood sugars are at bedtime, you may want to play around with the calories you take at night. Typically most of us consume most of our calories at dinner, or at least in this country. You may want to switch that to having a larger lunch or an afternoon snack and smaller dinner. You also may want to adjust your exercise program, if you're exercising in the morning but your sugars are high in the evening, switch your exercise program to the evening hours.

As far as when your doctor will start you on medications, I can't answer that.

"Weight loss, especially reduction in fat around the person's belly, helps improve sugars. But weight loss in any form will help diabetes and blood sugar control."

MEMBER QUESTION:
Does increased blood sugar cause weight gain?

NAZARIO:
It's usually the other way around. Increased weight gain causes insulin to work less efficiently, meaning insulin is less capable of lowering blood sugars. This is commonly called insulin resistance. As a result of continued weight gain and insulin not working as efficiently as it can, eventually blood sugars increase first into a range of prediabetes and then to higher ranges where a person gets diagnosed with diabetes.

Weight loss has the opposite effect. Weight loss, especially reduction in fat around the person's belly, helps improve sugars. But weight loss in any form will help diabetes and blood sugar control. One of the easiest ways to do that is to reduce your calorie intake by 500 calories a day, so you don't have to calculate how many calories you take every day, just eliminate 500 from your diet. That should lead to a 1 to 2 pound weight loss per week. Losing weight will improve your blood sugars.

MEMBER QUESTION:
There is no history of diabetes in my family, but I am overweight. I experience some numbness in my fingers, get frequent yeast infections, and have declining vision. I am trying to work on the weight problem. I could explain away the fingers (I type for a living), and everyone in my family wears glasses (besides once you reach the 50s a lot of us experience vision problems), but my diabetic girlfriend tells me that frequent yeast infections are a problem for women with diabetes and said I may have diabetes. I know you can't tell me if I have diabetes, but is it true that women with diabetes get a lot of yeast infections? Should I get my blood sugar tested?

NAZARIO:
Yes, women with recurrent yeast infections should be screened for diabetes, although being overweight puts you at risk for recurrent yeast infections. A simple fasting blood sugar is all you need.

MEMBER QUESTION:
I'm 35-year-old male, diagnosed with type 1 about 11 months ago. I am on Humalog and Lantus insulins. Up until about three months ago I required very little insulin at breakfast (1u:45g carbs). Recently I have had to increase my ratio at breakfast to 1u:15g, bringing it in line with lunch and dinner ratios. I had a C-peptide at six months after diagnosis. I'm still producing insulin, but just below the bottom of normal range. Would the change in insulin requirements be indicative of the end of the honeymoon period or that my islet cells have finally shut down completely (or are they the same thing)?

NAZARIO:
It looks like, from the information you gave me, the ratio of 1 to 45 now changed to 1 to 15 and you went from being sensitive to insulin to more resistant to insulin. That, to me, would not suggest that your honeymoon period is over. In other words, all you needed before was one unit for every 45 grams of carbohydrates, which is pretty good. That one unit can only take care of 15 grams of carbs, so you've become more resistant. If your honeymoon period were indeed over, I would have expected just the opposite. You are becoming more sensitive to insulin rather than more resistant to insulin.

As far as the C-peptide goes, I don't know under what circumstances the test was done. Time and time again I've seen the C-peptide test done wrong. If someone is trying to diagnose you with type 1 diabetes, a C-peptide test may help. But there's still a lot of overlap and the test may not give you any information. A GAD (glutamic acid decarboxylase) antibody, anti-insulin antibody or islet cell antibody is the profile you want to look at to determine whether someone really has type 1 diabetes.

Unfortunately, I'm still questioning the diagnosis of type 1 diabetes based on the small amount of information you gave me. It is unusual to be diagnosed with type 1 at such a late age, although it can happen. There are type 1s that are diagnosed later in life -- they are assumed to be type 2, but it's later discovered they're type 1. They don't really fit the profile of the classic type 1 diabetes and they are LADA (latent autoimmune diabetes in adults), or type 1.5 diabetes.

Look at our web site and find out information about this particular type of diabetes. I'm still not convinced what you have is type 1 based on the small information you have given me.

"One thing we should all know about diabetes is a little care goes a long way. The small steps we take today make huge steps in the quality of our life tomorrow, especially when it comes to diabetes."

MEMBER QUESTION:
I have two daughters; one is 20 years old and was diagnosed last year with type 1 and now also has Hashimoto's disease. Her sister is 11 years old and was just diagnosed with Hashimoto's disease; they both have goiters. How much of a risk is my 11-year-old for diabetes? No family members have either disease.

NAZARIO:
Your older daughter suffers from two autoimmune diseases. The type 1 diabetes and Hashimoto's are caused by her genetic makeup, making her more susceptible to these conditions. The younger daughter shares similar genetics, although not identical. Clearly she has already demonstrated susceptibility to autoimmune disease by having Hashimoto's. It's impossible to say whether the 11-year-old will develop type 1 diabetes or any other autoimmune disease. Having a particular genetics is just one facet of developing the disease. There are other triggers, including environmental triggers and a lot of unknowns about the autoimmune diseases. Although she has an increased risk, no one can tell you with certainty whether she will develop type 1 in her lifetime. The only thing anyone can tell you is yes, she has an increased risk, but she may never develop it.

MODERATOR:
We are almost out of time. Before we wrap things up for today, do you have any final words for us?

NAZARIO:
Please visit the WebMD Diabetes message board and post your questions. I try my hardest to answer as many questions as possible.

MODERATOR:
Our thanks to Brunilda Nazario, MD, for joining us today. And thanks to you, members, for your great questions. I'm sorry we couldn't get to all of them. For more discussion on this topic, be sure to visit the WebMD message boards to ask questions of our online health professionals, including Dr. Nazario, and to share questions, comments, and support with other WebMD members.

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