Meeting the Diabetes Challenge -- S. Sethu K. Reddy, MD. -- 11/18/02
By S. Sethu Reddy
WebMD Live Events Transcript
In recognition of National Diabetes Month, WebMD Live helped our members get the facts they need to prevent and properly treat this rapidly growing problem. S. Sethu K. Reddy, MD, from the Cleveland Clinic joined us to answer our members' diabetes questions.
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 WebMD Live. Joining us now is S. Sethu Reddy, MD, who is here to discuss meeting the diabetes challenge. Welcome, Dr. Reddy. Can you explain what is behind the rapid rise in diabetes over the last ten years or so?
Reddy: Very good question. Clearly in developing segments of American society and even across the world type 2 diabetes is increasing. People are paying more attention to dietary intake, but unfortunately, the amount of physical activity has declined even more, and this had led to increasing obesity over the last 20 years. This means if you belong to a high-risk group to begin with like Hispanic, East Indian, or African American and you develop obesity on top of this genetic risk, one is going to develop diabetes sooner. And this is part of the concern in that in many communities more adolescents and young people are developing type 2 diabetes. This is only the tip of the problem. These individuals will live longer and will have a chance to develop some long-term complications that are even more costly to the individual with diabetes, as well as to our healthcare system in general, of course.
Moderator: Are type 1 diabetes rates holding steady?
Reddy: I think the rates for type 1 diabetes have been relatively flat with an occasional flurry of cases sometimes in the spring or in the fall. But in general across the world the incidence of type 1 diabetes has been relatively steady. Over the last 50 years it's clear some countries have a much higher risk of type 1 diabetes. In particular it appears the further you are from the equator, the higher the chances of developing type 1 diabetes. For instance, some provinces in Canada and Finland have a higher incidence of type 1 diabetes than countries in the tropics. This may be linked to genetics as well as differences in environment in these regions.
We must remember type 1 diabetes is an autoimmune disease, where the individual develops high blood sugars in a short period of time, but in fact the pancreas is being attacked for many years before the high blood sugars. In general in the U.S. type 1 diabetes accounts for approximately 10% of all people with diabetes, and the remainder is type 2.
Member: What are the pros and cons of switching to an insulin pump? Are there any reasons not to use one?
Reddy: Good question. Insulin pumps are excellent devices to deliver insulin to someone in an elegant fashion. However, the patient must still control the pump. The commonest misconception I see in practice is that the patient thinks of a pump as a technique to automatically manage their sugars without having to check their blood sugars or having to think about their diet, or exercise activity. So typically, a patient using an insulin pump will monitor their sugars at least four to five times per day and will tell the pump how much insulin to give before their meals.
Currently, the pumps are indicated for people with type 1 diabetes. They are approved by Medicare if the individual's doctor can prove that the pancreas is not making any insulin. In the future when we have available a reliable implantable glucose sensor, we should see most people with type 1 diabetes on insulin pump therapy. The hope is that the glucose sensor will send information to the pump and regulate the amount of insulin being injected. This type of "closed loop" system will truly liberate the insulin-requiring patient.
Member: Does cholesterol-lowering medication reduce the risk of diabetes, or just heart disease?
Reddy: This is a fascinating question and there is recent information suggesting the class of medications we know as statins, which are powerful at lowering cholesterol seem to have some additional beneficial "side effects." There are some early research findings that suggest that Zocor and Lipitor may improve insulin sensitivity and thus may reduce the incidence of type 2 diabetes. Even more interesting is data from the West of Scotland Study, which looked at preventing heart disease with Pravachol. It was able to reduce the incidence of diabetes in the drug-treated group. Thus although more information is needed, this is interesting knowledge, but the most important facet for these medications would still be lowering cholesterol and preventing heart disease.
Recently, the highly publicized Diabetes Prevention Program trial was published in the New England Journal of Medicine, demonstrating that lifestyle intervention was able to reduce the development of type 2 diabetes by 60% and metformin was able to reduce the rate by about 30%. Other medications being studied at present to try and prevent type 2 diabetes include acarbose and rosiglitazone, nateglinide, and ramipril (an ACE Inhibitor). We will get information from these studies in the next two to three years.
An additional note regarding statins: There are preliminary reports that they may also be helpful in osteoporosis.
Member: Is there any truth to the claim that a diet high in refined carbohydrates can lead to the onset of type 2 diabetes?
Reddy: I think for years we have grown up with the misconception that highly refined carbohydrates (table sugar and sugar-containing foods) will cause diabetes. We can only safely say that diet rich in simple sugars is associated with cavities and not necessarily type 2 diabetes.
It appears that the overall number of calories we eat -- be it from fat or carbohydrates, simple or complex -- is more related to developing type 2 diabetes. The American Diabetes Association has recognized this and in their nutritional guidelines recommend that if desired, a person with diabetes may be able to eat up to 15% of their total daily calories from simple sugars.
As an example, it would be healthier for a person with diabetes to have a whole grain cereal with skim milk and a little bit of sugar rather than a low-fiber cereal with whole milk and no sugar. Another reason for this rationale is to get both patients and physicians to focus on the overall diet rather than just avoiding simple sugars alone.
Member: I am staying dizzy off and on during the day. Is that a sign of diabetes?
Reddy: Dizziness by itself is not necessarily a sign of diabetes. However, if it's related to dehydration from excessive urination from hyperglycemia, then it might be diabetes. The classic symptoms are usually:
- Increased urination
- Weight gain or weight loss
- Sometimes increased drowsiness after eating
- Getting up at night to go to the bathroom
Quick GuideType 2 Diabetes Diagnosis, Treatment, Medication
As you can see many of these symptoms could be considered as the same symptoms associated with aging. And it's unfortunate some people put up with the symptoms thinking it is a normal part of aging. The American Diabetes Association recommends individuals over age 40 or those at a higher risk of developing diabetes should be screened yearly with a fasting glucose check. So if you are concerned about diabetes, it should be easy for your physician to rule out.
Member: What are other less known complications?
Reddy: It depends on who you talk to and the background of the patient, but I would think that eye complications and kidney complications and foot complications are probably the most well known complications of diabetes. Lesser known complications include heart disease, neuropathy, and a particular kind of neuropathy that affects our internal organs including the heart, stomach, bladder, and erectile function. Heart disease is certainly well known by many patients, but few patients realize that diabetes is a major risk factor for developing early heart disease.
Over 100 years ago it was stated that knowing syphilis and all of its manifestations will lead to a physician knowing all of medicine. However, we have essentially eradicated syphilis, but in this century we can say that diabetes can affect every organ, usually through the neural or vascular mechanism, and this is why both the patient with diabetes as well as their doctor needs to be well educated about diabetes.
Member: Is diabetes caused by genetics, environment, or both and to what extent? Can the cumulative damage caused by environment, i.e., diet and exercise be reversed?
Reddy: Good question. Quite a bit is known about genetic and environmental influence on causing diabetes. If we look at the identical twin situation, it might help us understand the relationship better. If an identical twin develops type 1 diabetes, their sibling who has an identical genetic background has about a 50% chance of developing type 1 diabetes also. So clearly there must be an environmental trigger or process that is important. This could be a viral infection, some food toxin, or some pollutant. The exact nature of the environmental trigger, though, has not been well defined.
If you have a twin with type 2 diabetes, the identical twin has almost a 90% chance of developing type 2 diabetes. Obviously there is even a greater genetic component to type 2 diabetes. If a parent has type 2 diabetes, the children have a 25% chance of getting type 2 diabetes. And if both parents have type 2 diabetes, the children have a 50% chance of getting type 2 diabetes.
However, before we give up on environmental factors, it is obvious that type 2 diabetes is a relatively modern disease, growing exponentially in the last century. If you look at the Native American population, for instance, over 100 years ago, these individuals were extremely fit, active, and had little type 2 diabetes in their communities. Now, in some of these communities up to 50% of the adults have type 2 diabetes.
Recent intervention trials like the Diabetes Prevention Program in the U.S., and some earlier studies from China and Europe, confirm that lifestyle intervention has a dramatic impact at reducing type 2 diabetes. So although each of us may have a different baseline risk depending on our ethnic origin, changing our environment (meaning our lifestyle) is of tremendous importance.
Member: I have diabetes and have protein in my kidney that registers 1,000 in testing. What can I do to help my kidneys?
Reddy: You would seem to have proteinuria, which could be an early sign of developing kidney disease in someone with diabetes. Improved blood sugar control, improved blood pressure control, and a reduction in protein intake may all benefit the kidney.
Of all of these variables, having blood pressure control is probably the most important. There is also evidence that individuals who have protein in their urine are more likely to develop heart disease and vascular disease. So one would also like to reduce all of the cardiovascular risk factors such as cholesterol, smoking, and others.
Member: With proper care and treatment, what is the impact of diabetes on typical life expectancy?
Reddy: This is an excellent but sad question, because for the most part, we as a society have not aggressively treated individuals with diabetes to "appropriate" levels. Some data from the 1980s suggested that a person with type 2 diabetes will, on average, live five to seven years fewer than a non-diabetic individual. And a person with type 1 diabetes will have a lifespan that may be more than 15 years shorter than a non-diabetic individual.
However, I always encourage my patients to ignore this older information. This is of historical importance and one should not be fatalistic in assuming the same bad outcomes for those who develop diabetes now. In fact, many of my patients with diabetes lead much healthier lives than those without diabetes. And I would expect them to outlive many of the non-diabetics. We must remember there are many advances in preventing complications as well, which further enhance our optimism.
Member: My husband was just recently diagnosed with diabetes. He also has hepatitis C. Are these two illnesses related? Can they work against each other?
Moderator: Hepatitis C is a virally-related infection of the liver, so it's not directly linked to diabetes. Sometimes people with hepatitis C are treated with interferon therapy, which could cause some problems with autoimmunity and may be associated with autoimmune disease. Certainly people with diabetes are not necessarily at a higher risk of contracting hepatitis C.
Member: How can I become involved in a diabetes clinical trial?
Reddy: If you are interested in participating in clinical research, you should usually contact your local medical school or teaching hospital and inquire about research opportunities. We always appreciate our patients who participate in these clinical trials for the greater benefit of the diabetes community, with little self gain. Remember that these trials are highly selective and one may not necessarily qualify for a particular study. But perhaps you may qualify for another study. All of these trials have to be approved by the local ethical review board prior to being allowed to recruit subjects.
Member: What possible effects could a low-carbohydrate diet such as the Atkins kind have on a person with diabetes?
Reddy: Good question, since many patients have attempted the high-protein, low-carb diet on their own. Certainly when one reduces the amount of carbohydrates, one sees less hyperglycemia and an improvement in overall blood sugar control. On the negative side, if these people are eating more animal protein and animal fat, the risk of heart disease and some cancers may be increased. In practice, I have found very few patients are able to follow such an extreme diet for a long period of time.
Overall, most nutritionists and endocrinologists would recommend a healthy, balanced diet spread out across the day. Remember the total number of calories per day has to add up to 100%. If you cut back on one component, another component will be higher.
Moderator: We are almost out of time. Before we wrap up for today, do you have any final comments for us, Dr. Reddy?
Member: If you have diabetes you should try and take charge of your diabetes and know your numbers and follow your numbers as closely as you follow your retirement savings fund, your mutual funds or your stocks. The key numbers are for your blood sugar, hemoglobin A-1C, cholesterol, and blood pressure. Also, you should check with your healthcare provider and take advantage of all preventive medicine approaches. You can be healthy while having diabetes.
Moderator: Unfortunately, we are out of time. Thanks for joining us members, and thanks to the Cleveland Clinic's Sethu Reddy, MD, for being our guest. For more information on diabetes, visit WebMD's Diabetes Condition Center, message boards and read our archived chats on this subject in our Live Event Archive. Goodbye and good health!
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