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Ask an Endocrinologist: Understanding&Managing Diabetes

Online Health Chat with Leann Olansky, MD

November 6, 2012

Introduction

In 2010, over 21 million people in the U.S. had diagnosed diabetes. Approximately one in three people born in 2000 will develop diabetes according to the Centers for Disease Control and Prevention (CDC). Diabetes mellitus is a disease that prevents your body from properly using the energy from the food you eat. This occurs if the pancreas produces little or no insulin, or makes insulin but the insulin does not work as it should.

Diabetes mellitus (DM) is classified as DM Type 1 or DM Type 2, based on the age of onset and certain features of the disease. Juvenile diabetes, or DM Type 1, affects children, teens and young adults. Type 1 DM is an autoimmune disease that destroys certain pancreatic cells called beta cells, leading to a reliance on insulin injections. Latent Autoimmune Diabetes in Adults (LADA), or DM Type 1.5, affects adults with diabetes that is similar to DM Type 1. These patients have positive antibodies and a decreasing ability to make insulin. There is also no family history of DM Type 2. Type 2 diabetes is known to affect middle-aged patients who are obese (20 percent or more over desired body weight), as well as certain ethnicities (e.g., Black-American, Hispanic or Native American) or with other known risk factors. (Other types of diabetes also exist.)
People without diabetes have a normal fasting blood glucose of 70 mg/dl to 100 mg/dl. A diabetes diagnosis is made when:

  • A patient has a fasting blood glucose level of 126 mg/dl or higher on two separate occasions; or
  • A patient has a random blood glucose level of 200 mg/dl or greater and has common symptoms of diabetes.

To manage diabetes, patients must diligently measure their insulin levels; take oral medications, non-insulin injections or insulin injections; and monitor their diets and exercise levels each day.
People who need to take insulin injections should be seen by their physician every three to four months to monitor disease progression and the onset of any related complications. Diabetes can cause serious related complications, affecting the eye, kidneys and nerves, as well as causing delayed wound healing (particularly in the feet).

Proper management of diabetes begins with understanding the disease, the treatments and lifestyle changes that can allow patients to live longer with DM with fewer complications.

For More Information

On Cleveland Clinic
Cleveland Clinic’s Diabetes & Endocrinology Program is ranked second in the nation by U.S.News & World Report’s annual America’s Best Hospitals survey. Our diabetes education services help teach effective disease management including proper ways to monitor and normalize blood glucose levels, how to avoid long-term complications, strategies to control weight, and how to plan meals and read food labels. Our diabetes specialists can also provide current research findings, the latest information on nutrition, exercise tips and goal setting strategies.

On Your Health
MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: mychartsupport@ccf.org

A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult


For Appointments

November is Diabetes Awareness month! To make an appointment with Dr. Leann Olansky, or any of the other specialists in our Endocrinology & Metabolism Institute at Cleveland Clinic, please call 216.444.6568 or call toll-free at 800.223.2273, ext. 46568. You can also visit us online at www.clevelandclinic.org/endocrinology


About the Speakers

Leann Olansky, MD is a staff physician in the Department of Endocrinology, Diabetes and Metabolism, located on the main campus of Cleveland Clinic. She was appointed in 2006. Dr. Olansky is board-certified in the subspecialty of endocrinology by the American Board of Internal Medicine. Her particular interests include diabetes, diabetes complications and glucose sensing technology for the management of diabetes.

Dr. Olansky completed her fellowship in endocrinology at the University of Virginia Medical Center in Charlottesville, Va, after completing her residency and internship in internal medicine at Georgetown University Hospital, in Washington, DC. Dr. Olansky graduated from medical school at Emory University School of Medicine, in Atlanta, Ga.


Let’s Ask an Endocrinologist: Understanding and Managing Diabetes

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Leann Olansky. We are thrilled to have her here today for this chat on Diabetes.

Diagnosis of Diabetes and Insulin Resistance

brilliant: How does a patient know if they are not producing enough insulin nor have insulin resistance?
Dr__Olansky: We can do a blood test called a c-peptide. This is a fragment cleaved off the precursor of insulin. When it is very low, we know that that person is not making much insulin. This patient will probably have to be treated with insulin and injections or with an insulin pump.

thanksgiving: What is A1C?
Dr__Olansky: A1C is short for hemoglobin A1c. Glucose attaches to the last amino acid in hemoglobin. This changes the charge, and it can be separated from the hemoglobin that has not been modified. The higher the glucose, the more hemoglobin has glucose attached, so it becomes a measure of how high the glucose has been for the life of a red cell (about 120 days).

nystr: How strong is the hereditary risk factor for diabetes if my father became diabetic in his 40s? He was overweight. I am not overweight and my numbers have been good when I get a physical. But will I still have a possibility of getting diabetes if I am doing everything to prevent it? Can diabetes totally be prevented?
Dr__Olansky: You are at greater risk for diabetes mellitus than if none of your relatives had it, but keeping your weight down, eating healthy and getting regular exercise is a great way to keep from realizing your genetic potential.


Heart Disease and Diabetes

sinaihospital: I have Type 2 diabetes. Is there a link between diabetes and heart problems?
Dr__Olansky: Epidemiologic data shows a correlation between heart disease and Type 2 diabetes. It is not clear if all can be attributed to the association of hypertension, abnormal lipids and obesity that frequently accompanies Type 2 diabetes, or if there is additional risks that are yet to be identified. The good news is that attention to control of blood pressure and cholesterol can reduce the risk for heart problems in people with diabetes.


Neuropathy

myadvocate: I have been diagnosed with small fiber neuropathy (SFN) at Cleveland Clinic. The leading cause of this is diabetes. I have had two negative results for both the A1C and the glucose tolerance tests. Are there other metabolic problems that are not picked up with these tests? All of the other possible causes for my SFN also have been ruled out.
Dr__Olansky: It has recently been noted that metabolic syndrome (high triglycerides and low HDL [high density lipoprotein] cholesterol as well as hypertension) can be associated with small fiber neuropathy. A drug that lowers triglycerides and raises HDL cholesterol called fenofibrate has shown benefits in diabetic neuropathy and may be helpful to you if you have those abnormalities.

no_show: What are the symptoms of neuropathy?
Dr__Olansky: This can be pain or a numb feeling that generally starts in the feet, but can be in the hands and arms as well. Sometimes it is a prickly sensation.


Hyperthyroidism and Diabetes

nutzy_1: I've got thyreotoxicosis after amiodarone treatment for atrial fibrillation (flutter). On my last blood test, my glucose was 125 on an empty stomach. Is there any connection between hyperthyroidism and diabetes? I have to mention that my mother suffered from diabetes during her final years.
Dr__Olansky: Yes, particularly if your hyperthyroidism was Graves disease. This is an autoimmune disease that can be associated with damage to the cells that make insulin. Sometimes blood glucose goes up when a person has hyperthyroidism and comes down when they return to normal, but I would continue to watch your blood glucose as you are now considered pre-diabetic.


Diabetes and Polymyalgia Rheumatica

grkbfd: With Type 2 diabetes and polymyalgia rheumatica (PMR), how do these affect each other?
Dr__Olansky: Polymyalgia rheumatica is usually treated with prednisone, but prednisone causes insulin resistance. This will raise the blood glucose in people with diabetes or prediabetes.


Foot Ulcers

mj22: What is the best treatment for ulcers on the leg resulting from Type 2 diabetes?
Dr__Olansky: The best treatment for foot ulcers in patients with diabetes is to keep the ulcers clear, treat any infection with antibiotics and keep the pressure off the ulcer. This patient might need a special shoe if the ulcer is on the bottom of the foot. Crutches may be used and avoid bearing weight on that foot. In some patients, hyperbaric oxygen can help.


Elevated Lactate

sam500016: I have Type 2 diabetes and I have been on metformin (500 mg twice daily) for the past four years. It appears to agree with me and I am able to maintain my A1C level around six percent. However, my serum lactate is more than 2.4, which is very high. How should I deal with my high lactate level ?
Dr__Olansky: I would not worry about an elevated lactate as long as your kidney function is normal and you feel well. We know metformin interferes with lactate conversion to glucose, so that is why yours is somewhat elevated. However, lactic acidosis makes you feel sick.


Statins and Diabetes

thereg: What can you tell me about taking statins and high fasting glucose results? Before lowering my cholesterol with statins, my fasting glucose was normal. Now the doctor says I have pre-diabetes
Dr__Olansky: In a large state trial called Jupiter, it was shown that there was more diabetes in patients that received the statin drug, but all the people who developed diabetes had either a fasting blood glucoses above the normal range or a HgbA1c that was in the diabetic range. What they found is that those people on statin developed diabetes a few months sooner than those without. In other words, the statin seemed to uncover diabetes that was going to show up in a few months anyway. We know that statins prevent heart attacks and strokes in people with diabetes, just as they do in people without diabetes, so it is worth it to take them.

xJanL: I'm a 62-year-old female with Type 2 diabetes. My A1C runs 6.2 and my blood pressure is 140/86. I’m on medications for both. Recently, my physician put me on lovastatin. My HDL (high density lipoprotein) is 56, and my LDL (low density lipoprotein) is 118. My total cholesterol is 228 and my triglycerides are 268. My last examination revealed that my kidneys are leaking a little, but nothing at present for concern. Once this starts, do they ever get better? Do I just maintain or does it get worse?
Dr__Olansky: The protein in your urine may go back to normal with better blood pressure (BP) control (130 systolic or less)and with certain BP medications called ACE (angiotensin-converting enzyme) inhibitor or angiotensin receptor blockers. Do not get discouraged about this.


Medications for Diabetes

trinity: Is there a point in diabetes when insulin and several pills don’t respond or do well?
Dr__Olansky: Usually the combination of insulin and pills can be used to control most patients. There are new drugs working in different ways that can be used with other pills or with insulin, so that most patients can be controlled.

sellers: Can metformin, Byetta® or Victoza® be helpful to a Type I diabetic in addition to taking rapid-acting insulin? Does cirrhosis of the liver affect the action or duration of insulin?
Dr__Olansky: People are just beginning to look at Victoza® -and Byetta®- type agents in Type 1 diabetes, but we do not have much information about this yet. Cirrhosis can increase the risk for hypoglycemia, especially if on insulin.

indy: Does it make a difference when you take metformin, i.e. before a meal, with a meal, after a meal or two hours after a meal?
Dr__Olansky: The only reason metformin is recommended with food is that gastrointestinal (GI) symptoms are lessened that way. If there are no GI symptoms, it can be taken before or anytime after a meal.

BEACHBABIES: I take Janumet® 50/1000 twice daily. My A1C and glucose numbers are all great. Do I need to continue the medication? Am I still considered diabetic?
Dr__Olansky: Yes, you still have diabetes. You are a well-controlled diabetic. I would continue the therapy as this is your best chance for avoiding complications that can come with diabetes. Sometimes when you go off and only restart if your glucose goes up, you do not have a good response as if you had stayed on the agent that got you there.

xJanL: I know Motrin® is hard on the kidneys, so I discontinued taking 800 mg daily (with a microalbumin/creatinine of 166 mcg), but I ache a lot. Would it be O.K. if I take half of one once in a while for relief without harm? Tylenol® is almost useless.
Dr__Olansky: Motrin® and similar drugs interfere with the benefits seen with ACE (angiotensin-converting enzyme) inhibitors and angiotensin receptor blockers. They can also raise blood pressure. Talk with your doctor as there are other agents that can help with pain, particularly neuropathic pain.


Alternative Therapies, Nutrition and Supplements

pdt: Are there any recommended supplements that would be of benefit to most patients with both diabetes and heart disease?
Dr__Olansky: There is a possible improvement in heart disease risk with fish oils. Cinnamon has been shown to help diabetes in some patients with Type 2 diabetes. Vitamin D is an important supplement that seems to improve the risk for heart disease, osteoporosis, cancer, infection and maybe diabetes, so I recommend that to everyone—especially people who live in northern states.

beachhouse102: I take 2000 mg of metformin daily for Type 2 diabetes. I am noticing that since I started taking this I am experiencing brittle nails and a noticeable loss of hair. I am concerned that besides blocking the absorption of sugar, the medication is causing malabsorption of some other vital vitamins or minerals. Could this be possible?
Dr__Olansky: We do not think metformin blocks the absorption of glucose, but it does interfere with absorption of vitamin B12. I don't think this is the cause for your hair and nail problems, but should be checked. Vitamin D deficiency may affect hair and nails. Vitamin D supplements of 2000 units per day should replace the deficiency for most people.

chief: If metformin lowers vitamin B12 in blood serum, then can over-the-counter B12 supplements compensate for that loss?
Dr__Olansky: Yes. We recommend that.

erick: Does white bean extract help lower blood sugar? What is it made from?
Dr__Olansky: Sorry, I do not know about that, but many foods, especially whole grains and high fiber foods stimulate hormones from the intestine that do help with diabetes.

jet_sets: What about substituting artificial sugar? How do these count as carbohydrates?
Dr__Olansky: If there are no calories, there are no carbohydrates.


Exercise

now_now: What about exercise for someone with Type 2 diabetes? Is moderate considered good and extreme bad?
Dr__Olansky: Exercise is good for Type 2 diabetes. If you have complications, you may need to modify what you do for exercise. Walking is O.K. for most people, but if you have severe neuropathy and deformity in your feet, water exercise may be better. If you have significant retinopathy, be careful in lifting weights and you should not be hanging upside down.


Closing

I'm sorry to say that our time with Cleveland Clinic specialist Leann Olansky, MD is now over. Thank you Dr. Olansky for taking the time to answer our questions today about ‘Ask an Endocrinologist: Understanding and Managing Diabetes.’
Dr__Olansky: Thanks for the great questions. I hope this has helped you understand diabetes better.


Contact Information

For more information about diabetes, please visit http://my.clevelandclinic.org/disorders/diabetes_mellitus/hic_diabetes_overview.aspx

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