|
PRx Host : |
Umesh Masharani is an assistant clinical professor of endocrinology, with a specialty in diabetes, at the University of California-San Francisco. I want to start tonight by talking about the team concept of diabetes care. I know that a patient needs more than one specialist for complete care. Other than his primary doctor, what other doctors should a diabetic person see?
|
|
Dr. Masharani : |
I think that because diabetes is such a complex condition, affecting many parts of a person's life, you need a team to teach you how to look after diabetes. This team usually consists of a nutritionist, a diabetes nurse educator, a clinical psychologist or social worker, the patient, and the diabetologist. This is to help the patient and his family manage this condition. When a person with diabetes develops complications from the condition, he will need to see perhaps a renal (kidney) doctor. He definitely will need regular exams by an ophthalmologist, a dentist, and a podiatrist. There may be needs for other doctors, such as neurologists, vascular surgeons, gastroenterologists, and others, depending on the complications.
|
|
PRx Host : |
Let's talk about the nutritionist first. What role does nutrition play in diabetes control? Is it more than just avoiding sugar-heavy foods?
|
|
Dr. Masharani : |
Nutrition forms a foundation of good diabetes care. A patient with type 1 diabetes who is taking insulin needs to know how food affects blood glucose and how much insulin will bring down the glucose level for the food consumed. He also needs to learn how to "spread" the foods that raise blood sugar, that is, carbohydrates, throughout the day so that glucose fluctuations in the blood can be minimized. A patient with type 2 diabetes needs to be taught about carbohydrates and how to spread them throughout the day to avoid large rises in blood glucose levels. Patients with type 2 diabetes are often overweight, so they also need to learn how to reduce their calories and lose weight. I do not usually talk to my patients about sugar, but, instead, about carbohydrates, which are the foods that raise blood sugar. I also do not teach my patients to buy diabetic foods. I don't think that is usually necessary. In fact, if someone with diabetes wants to eat sweets in moderation, we can teach them how to do so without raising their blood sugar.
|
|
PRx Host : |
Are there real dangers for diabetics drinking hard liquor? My friend's mother is a diabetic and an alcoholic.
|
|
Dr. Masharani : |
Depending upon the medications a diabetic is taking, alcohol usually causes your sugar to fall too low. Obviously, alcoholism is an illness on its own and, in fact, can cause pancreatitis and a form of diabetes. I think drinking excessively is clearly a problem in all people, not only in people with diabetes.
|
|
AlexF : |
Have you heard anything about how diabetics are affected by an Atkins'-type low- to no-carb diet?
|
|
Dr. Masharani : |
I have not read Dr. Atkins' book, but I understand that he advises, as you've stated, a very-low-carbohydrate diet. This need not particularly be a problem, provided you are not substituting it with a very-saturated-fat diet, because patients with type 2 diabetes have higher risks of cardiovascular disease. Thus, a high-fat diet can be detrimental. Patients with type 1 diabetes on an extremely low carbohydrate diet might have difficulty getting smooth glucose control. Also, if you have diabetes kidney disease, a very high-protein diet might cause progression of the kidney disease.
|
|
PRx Host : |
Back to the team. Why is a social worker necessary?
|
|
Dr. Masharani : |
When a patient learns that he or she has diabetes, they're often very angry that they now have a chronic illness. They often go through a grieving stage that they've lost their health, that their diabetes impacts all aspects of their lives. It also affects their families, especially if there are complications from the condition. I think counseling with a clinical social worker or a clinical psychologist helps a patient come to terms with his or her illness and incorporate the changes that we ask of our patients into their daily lives.
|
|
zrica : |
What is the best way to support a diabetic? My mother is a recently diagnosed diabetic and she doesn't seem to worry that much. Should I worry for her?
|
|
Dr. Masharani : |
I think it would be very useful for your mother to go to a diabetes education program to learn about diabetes and how she can learn to manage it. It may help your mother if you go with her. In the end, it has to be your mother who has to take care of her diabetes. I think family support is very important, and perhaps it would be helpful if you can support her with any dietary changes and with her medications and monitoring. Diabetes is a family disease.
|
|
PRx Host : |
You mentioned eye doctors. How does diabetes affect the eyesight?
|
|
Dr. Masharani : |
Diabetes affects the eyes in a number of ways. People with diabetes are more prone to cataracts and glaucoma. It can also reduce the blood flow to parts of the retina, and when this happens, it can cause new blood vessels to form in the retina. These are very fragile and can sometimes break and cause bleeding. Diabetes is the most common cause of blindness in the United States, and this is unfortunate because it is preventable. No patient with diabetes need go blind, provided that measures are taken to keep glucose levels and blood pressure under control. It is also important to have regular eye exams. Even early changes in a diabetic's eyes can be treated and blindness prevented, provided an ophthalmologist is seen at regular intervals.
|
|
JohnJumpsUp : |
Is there any kind of food that I should avoid to keep from getting cataracts and glaucoma?
|
|
Dr. Masharani : |
I don't know of any.
|
|
PRx Host : |
I know that many diabetics have some form of amputation, particularly in the legs and feet. Is that why you recommended a foot doctor? What causes the necessity for amputation?
|
|
Dr. Masharani : |
I'm glad you asked me this question! Like the question regarding the eyes, foot problems are preventable. There are two reasons why people with diabetes get into trouble with their feet. First, the high sugar can damage the nerves in the feet, so the patient can't feel things easily. So, if you step on a piece of stone and it hurts you, you won't know about it. We call these "insensate feet." When this occurs, it is really important to get regular diabetes foot care to avoid foot ulceration.
Another reason why people with diabetes get into trouble with their feet is when there is a problem with the circulation to the legs. Smoking and high-fat diets are risk factors for circulation problems, and if there are problems with the circulation, a foot ulcer will not heal.
Another problem with nerve damage to the feet is that it changes the shape of the foot so that the pressures of walking are concentrated on only very small areas of the feet. This causes calluses and ulcerations. These are the reasons why it is important to see a foot doctor who will teach you how to look after your feet, will treat your calluses, and teach you how to avoid ulcerations.
I should point out that if people with diabetes do not have circulation problems or nerve problems in their feet, then they are not likely to get into problems with ulcerations and amputations. Again, good blood-glucose control will prevent the development of these complications.
|
|
Poptart5 : |
At what age should I start to worry about my feet?
|
|
Dr. Masharani : |
You should worry about your feet when there is some numbness in them. You should also worry about your feet if there is a problem with the circulation. Your doctor will be able to tell you if this is the case when he examines your feet. It usually does not occur for several years after you develop type 1 diabetes. People with type 2 diabetes often have had high sugars for several years before they were diagnosed with the illness and, so, in these individuals, foot problems can be present when they are first diagnosed with diabetes.
|
|
inddavid : |
For our host -- how long did it take you to accept your diabetes?
|
|
PRx Host : |
For the first three months after the diagnosis, I did nothing but embark on a weight-loss program. Then I went to a three-day program at UCSF and learned that there was a lot more to it than that. I'm happy to say that I recently had my HbA1c [glycosylated hemoglobin] test and the results were extremely encouraging. Perhaps Umesh would like to talk about that test a little bit.
|
|
Dr. Masharani : |
Everyone's body is swimming in sugar because, if you didn't have sugar, your brain wouldn't work. Everything, therefore, gets a sugar coating. Now, we can measure the thickness of the sugar coating. It's like an M&M coating, if you like. If your sugar is high, you get a thicker coating. I can take a blood sample and look at the sugar coating on the hemoglobin and if a patient's sugars have been running high, the coating is thicker. We know that the higher the sugar coating, the more likely a patient is going to have complications from diabetes. Now, this sugar-coating test is done every three months because it takes that long for it to change. So this test gives you an idea of where your sugar is running in your blood over a three-month period.
|
|
jenikochan : |
My uncle is convinced that if he just loses a few pounds, he'll no longer be diabetic. Is that true?
|
|
Dr. Masharani : |
I think losing weight, if you're overweight, will usually help people's sugar, but this is not the only thing. Exercise is also quite important and, for a number of people, losing weight only marginally improves the glucose values. As our host mentioned, he had to do more than just lose weight. Remember that, in addition to a weight problem, there is also a problem with insulin secretion from the pancreas.
|
|
PRx Host : |
Back to the team one more time. How does diabetes affect the kidneys? Is it necessary to go to a special kidney doctor?
|
|
Dr. Masharani : |
If your blood sugar is very high, it damages the kidneys so that you start spilling extra protein (which is normally circulating in the blood). If you don't do anything more, eventually your kidneys will fail completely and you would have to go on dialysis or get a kidney transplant. Kidney failure also causes your blood pressure to go up and this, in itself, causes further kidney damage. Again, I need to emphasize that if you keep your blood-glucose levels and blood pressure under good control, there is no reason why you would have kidney damage so it is not necessary to see a kidney doctor. I do recommend to my patients to have a special test on a yearly basis to look for kidney damage. The test is called microalbuminuria and it's an extremely sensitive test that looks for kidney damage. The good thing is that if we catch the damage at this point, we can give medications which can prevent progression of the damage and, in fact, even reverse it a little bit.
|
|
PRx Host : |
Let's talk a little about hypoglycemia. First of all, what is it? Why does it affect people with diabetes? Is it dangerous? How can it be controlled?
|
|
Dr. Masharani : |
Hypoglycemia is when your sugar in your blood falls below the normal range. As I mentioned to you, your brain needs sugar to work properly, and when your sugar falls too low, you can get confused and not function properly. It can occur in people with diabetes who are taking oral medications or insulin, which can cause the sugar not only to become "normal," but to fall too low.
|
|
PRx Host : |
How would I know if I had an episode of hypoglycemia? If I suspect I have, what should I do about it?
|
|
Dr. Masharani : |
The body has a lot of mechanisms for raising blood sugar. Because of the need of the brain for the "stuff," when your sugar falls too low, you start shaking, you may feel sweaty, you may have palpitations, and you may feel the same things as you might do if a saber-toothed tiger were sitting next to you! What I would recommend is that you should try to check your sugar at the time on your home machine. If you don't have time to do that, I would take some sugar, and you will feel better. You can take sugar lumps, you can take juice, and you can take glucose tablets. Don't take chocolates and don't take foods that don't contain carbohydrates.
|
|
PRx Host : |
What about children with diabetes? Are they at any special risk for hypoglycemia? How does a parent monitor the glucose level of a child?
|
|
Dr. Masharani : |
Yes, children are at more risk for hypoglycemia. First of all, the majority of them have type 1 diabetes and are on insulin and are, therefore, more fragile. Also, children have a lot of unpredictable activity like playing and this can cause the sugar to fall rapidly. It's also hard to convince a young child to eat their food when you know that they've already had their insulin. A parent monitors the glucose level using the home blood-glucose monitor. Teachers can also do this in the classroom and you need to do this at least four or five times a day when the child is behaving oddly or when they tell you that their blood levels are low. There is also a problem of nighttime low sugars and we often ask the parents to wake up at 2 a.m. to check the child's sugars. Children's brains are more sensitive to the negative effects of low sugars and it is very important to monitor blood glucose frequently. We also try not to get their blood glucose as tightly controlled as we might an adult with type 1 diabetes whose brain is a little bit more resistant to the effects of low sugars.
|
|
JohnJumpsUp : |
Are you at higher risk for diabetes if you are hypoglycemic?
|
|
Dr. Masharani : |
Hypoglycemia can occur as part of a pre-diabetic state, but that is very unusual. I have met many patients with diabetes and the majority of them never had low sugars before the diagnosis. It does occur, but it is rather unusual. I can, right now, think of only one patient of mine who exhibited this problem.
|
|
Poptart5 : |
I kind of have a sweet tooth. Can I get diabetes from eating too much junk food?
|
|
Dr. Masharani : |
Provided you're not overweight, and provided you don't have a strong family history of diabetes, I think the sweet tooth will only affect your teeth!
|
|
AlexF : |
Are there more diabetes cases in the U.S. than in the rest of the world?
|
|
Dr. Masharani : |
No. Diabetes occurs all over the world and it's a reflection of a Western lifestyle. For example, when Japanese people immigrated to the United States and adopted a Western diet, they got diabetes. There's a higher incidence of diabetes in Hispanic, African-American, and American Indian populations. This is undoubtedly related to environmental factors in addition to a probable genetic predisposition.
|
|
PRx Host : |
When you say environmental factors, to what are you referring specifically? Usually related to obesity, and that is related to high-fat and processed foods.
|
|
Dr. Masharani : |
Usually related to obesity, and that is related to high-fat and processed foods.
|
|
PRx Host : |
Do we understand exactly why obese people have a greater incidence of diabetes?
|
|
Dr. Masharani : |
Yes, obese individuals need more insulin to get their glucose into their cells. In other words, their bodies are less sensitive to insulin. If they also have a genetic problem so that their pancreas cannot keep up with their insulin needs, then they get diabetes. If they lose weight and exercise regularly, then their bodies become more sensitive to insulin and so the amount of insulin that the pancreas makes is sufficient and their glucose stays normal.
|
|
PRx Host : |
Is that the reason why pregnant women sometimes get diabetes? After the birth of the baby, can a woman who's had diabetes in pregnancy go back to normal blood sugars? What steps should she take?
|
|
Dr. Masharani : |
That is a great question! Yes, pregnancy increases the body's need for insulin and if you can only make a limited amount, then you develop diabetes of pregnancy. Usually, after the pregnancy, the insulin requirement falls and the sugars become normal. What this tells us is that if that lady becomes overweight in the future, she's more likely to develop diabetes. We know from studies that people who have diabetes during pregnancy are more likely to develop diabetes in the future even if they don't gain much weight. This is probably because whatever is causing the pancreas to limit insulin secretion is progressing with aging. I tell ladies who have pregnancy-associated diabetes to make sure they don't gain weight and also to have a regular check-up with their physician to make sure they haven't developed diabetes.
|
|
WhyMeWhyNot : |
You mean you can cure yourself of diabetes sometimes?
|
|
Dr. Masharani : |
I think you can get your diabetes under control with diet and exercise so that your sugars are normal. You probably haven't corrected the underlying problem in your pancreas. And if you become overweight or become pregnant, you will probably have high sugars again. Unfortunately, the pancreatic process may progress even if your weight stays normal so that in the future, you may need medications to control the sugars. What this means is that just because your diabetes is well-controlled with diet and exercise now, it doesn't mean you should stop going to your doctor or monitoring your sugars at regular intervals.
|
|
Poptart5 : |
Are there HMOs with team-care networks set up?
|
|
Dr. Masharani : |
HMOs may give authorization to your doctor to send you to a diabetes center that has a team. An HMO does not itself have a diabetes team. Perhaps PRx Host can answer that.
|
|
PRx Host : |
I can't. One last question, doctor. We've had several questions about genetics and diabetes. Are both type 1 and type 2 diabetes genetically linked? Are there any special steps a person with a family history of diabetes should take?
|
|
Dr. Masharani : |
Yes, both forms of diabetes have a genetic basis, but in different ways. Type 1 diabetes is an immunological disease and it is linked to the HLA immune genes. Most people with type 1 diabetes inherit a certain forms of these HLA genes. However, most people with type 1 diabetes do not have family members with the disease. Type 2 diabetes has a stronger inheritance and, generally speaking, a lot of people have family members with the disease. The main step a person with a family history of diabetes can take is to make sure that they have an occasional evaluation by their doctor. They should also make sure that they do not gain weight and to exercise regularly.
|
|
PRx Host : |
You've been a great doc, Doc. Thank you for speaking tonight and thanks to everyone who asked questions. Bye for now.
|
|
Dr. Masharani : |
Bye-bye, and thank you!
|
