Online Health Chat with ­ Seenia Peechakara, MD

November 15, 2013


Over 18 million people in the U.S. have been diagnosed with diabetes. The disease of diabetes mellitus 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 type 1 DM or type 2 DM, based on the age of onset and certain features of the disease. Juvenile diabetes, or type 1 DM, 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 type 1.5 DM, affects adults with diabetes that is similar to type 1 DM. There is no family history of type 2 DM. These patients have positive antibodies and a decreasing ability to make insulin. Type 2 diabetes mellitus 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.)

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

About the Speaker

Seenia Peechakara, MD is an endocrinologist in the Department of Endocrinology, Diabetes and Metabolism at Cleveland Clinic. Dr. Peechakara is board-certified in internal medicine and endocrinology, and specializes in diabetes, gestational diabetes, thyroid cancer and calcium metabolism.

Dr. Peechakara completed her fellowship in endocrinology, diabetes and metabolism at Cleveland Clinic after her residency in internal medicine at MetroHealth Medical Center, in Cleveland, and at Saint Elizabeth Medical Center, in Boston. She graduated from medical school at Dr. D.Y. Medical College, University of Mumbai, in Mumbai, India.

Let’s Chat About Ask a Diabetes Expert

Diabetes Diagnosis: Signs and Symptoms

kathy: What are the symptoms of diabetes? How would I know if I should get a checkup?

Seenia_Peechakara,_MD: The common symptoms of diabetes weight loss, going to the bathroom to urinate often, increased thirst, increased appetite, blurry vision, headaches and hunger pangs. If you are concerned, ask your physician for a baseline screening for diabetes mellitus.

newbie: Can type 2 diabetes mellitus (DM) progress into type 1 DM, or are they entirely different diseases?

Seenia_Peechakara,_MD: Type 2 DM is a combination of insulin resistance and a mild degree of insulin deficiency. Type 1 DM is insulin deficiency—the kind that children are born with where they have hardly any pancreas left. Type 2 DM can convert to type 1 DM in a small population of patients who have antibodies to the pancreas, which destroy the pancreas and essentially make them type 1. However, we call this latent autoimmune diabetes (LADA) or type 1.5 DM. The other scenario is when a type 2 DM patient is so advanced in the disease that his/her pancreas has completely burnt out and behaves like type 1 DM. We still call this type 2 DM, but, specifically, insulin-dependent type 2 DM.

mattie: How does a patient know if they are not producing enough insulin or have insulin resistance?

Seenia_Peechakara,_MD: There is a blood test to measure the amount of pancreatic reserve. It is called C peptide. It is not a straightforward interpretation and the circumstances of ambient blood sugar, medications and other factors need to be considered.

Insulin Deficiency

Monalea: I have type 1 diabetes mellitus (DM), but formerly had type 2 DM for 35 years. I have tried Victoza® (liraglutide [rDNA]), which suppresses my appetite somewhat, but even though blood sugars run lower during the day, they creep back up to over 300 in the morning. Can you shed some light on this?

Seenia_Peechakara,_MD: That is expected in someone with insulin deficiency. If you have been diagnosed as having type 1 diabetes, then it means that you need insulin to help with the dawn phenomenon—which is an early morning rise in blood sugars.


nutzy: I am a 67-year-old female with a mitral mechanical valve and pacemaker implants for sick sinus syndrome (SSS), also known as sinus node dysfunction (SND). At my last visit I was diagnosed with diabetes. I take Januet (metformin) and have a hemoglobin A1C of 6.8. I am experiencing numbness in both legs. A clinical neurologist examined me and was not 100 percent sure it was neuropathy—but testing possibilities are limited because of my pacemaker. I interrupted my statin medication but there was no change. I also take diltiazem 60 mg and beta blockers. How can the cause of this numbness be diagnosed?

Seenia_Peechakara,_MD: Neurologists can do small fiber nerve testing to diagnose if it is neuropathy. Other common causes that need to be checked for include iron deficiency and vitamin B12 deficiency. This is especially true since you are on metformin, which is known to cause vitamin B 12 deficiency. Taking a vitamin B 12 supplement would be beneficial.

noahbuilt: Please help me the neuropathy I feel in my feet. I have taken Lyrica® (pregabalin), but nothing seems to take the numbness away. Do you have any suggestions?

Seenia_Peechakara,_MD: The different treatment options are Neurontin® (gabapentin), Lyrica® and— if it is really bad—local nerve blocks. You should consult a neurologist to make sure there is no other contributing cause, and have your physician check your vitamin B 12 levels. A deficiency of vitamin B12 would worsen neuropathy.

Lacey: I have heard of tingling in the feet with diabetes mellitus (DM), but what about the fingers? I have had tingling in my fingertips for a couple of months now.

Seenia_Peechakara,_MD: Neuropathy due to DM can affect both hands and feet. It basically affects the small fiber nerve endings first, which are present in both hands and feet

Diabetes with Associated Heart Disease and Other Health Conditions

sinaihospital: I have had type 2 diabetes mellitus since 2010. My internist said it was caused by my high blood cholesterol and my hypertension. His diabetes nurse said I should be careful about what I eat and have my checked blood sugar at the visits. I was sent to the diabetes doctor for a complete work up of my blood and urine. I was given a machine to check my blood sugar at home and medication for my type 2 diabetes mellitus (DM). Is there is a greater risk for people with type 2 DM getting heart disease and having a heart attack than those without type 2 diabetes? Am I at high risk for a heart attack due to my type 2 diabetes?

Seenia_Peechakara,_MD: Yes, diabetes is considered a risk factor for cardiac problems including a heart attack. Keeping your blood sugar, blood pressure and cholesterol well controlled will lower your risks quite a bit. Aiming for HbA1c (three-month blood sugar average) less than 7 would be ideal.

howard: Is there any connection between gout and diabetes?
Seenia_Peechakara,_MD: There is no direct connection, but some gout medications can cause hyperglycemia.

smith3: Can you elaborate on the connection between sleep apnea and diabetes mellitus (DM)? Can a slightly underdeveloped optic nerve be a symptom of diabetes?

Seenia_Peechakara,_MD: Sleep apnea worsens insulin resistance and can worsen DM. An isolated optic nerve issue is not a common manifestation of DM.

packersnate: Are people with diabetes mellitus (DM) at a higher risk for dental problems like gum disease? Should I tell my dentist that I have DM?

Seenia_Peechakara,_MD: There is no convincing data to suggest that all diabetics have poor dental health. But having said that, poorly controlled DM does make one prone to infections and poor health—including dental health. Letting your dentist know that you have DM would be prudent. Given this knowledge about your medical condition, your dentist will be able to choose the correct products for treatment.

pburke: I have heard about a connection between type 1 diabetes mellitus and type A positive blood type. What are your thoughts on this?

Seenia_Peechakara,_MD: As far as I know, there is no direct link between a person's blood type and autoimmune type 1 DM. That would be an interesting hypothesis for a medical research study though.

Testing and Levels: Blood Glucose and HbA1C

reed323: Can the meter reading scale be different for each individual? I feel better in the 140 to 170 range.

Seenia_Peechakara,_MD: Yes, how each individual feels can vary for a given blood sugar. The recommended goals are fasting blood glucose between 80 and 120, and two-hour post-meal readings are preferable less than 150, but up to 180 is acceptable. These are guidelines and each patient’s needs should be individualized.

hembra: Is it possible to suffer from diabetes even if my sugar count is ok, at 75? I get a tingling feeling in my toes at night.

Seenia_Peechakara,_MD: The diagnosis of diabetes is based on a fasting blood sugar greater than 126, or HbA1c (three-month average) of 6.5 or greater. Some patients do manifest neuropathy symptoms early in the prediabetic stage, which is a fasting blood sugar in the 100 to 126 range and HbA1c in the 5.7 to 6.4 range. Ask your physician to check these parameters to help in the diagnosis.

Clara35: My 85-year-old mother had pancreatitis and was hospitalized. She was on only intravenous fluids in hospital, and they included glucose, for at least a while. A month and a half prior to hospitalization her A1C was 6.2. At her follow-up visit with her primary care doctor, she was diagnosed with type 2 diabetes with an A1C of 7.1. After several months of doing nothing different except for eating fewer sweets and carbohydrates, her A1C dropped to 6.4. I was wondering if active pancreatitis somehow elevated what the A1C measures. (I know eating better is a good idea anyway, and an A1C 6.4 is not ideal, but since both things seemed to happen pretty much at the same time, it makes me wonder if they are related in some way).

Also, during the follow-up appointment her primary care doctor took her off the Pravachol® (pravastatin sodium). She just been put on this medication by the cardiologist at the hospital when she had pancreatitis. Her cholesterol is below 200, with a 51 HDL, and had a normal level of “bad" cholesterol. In her situation, how important is lowering her cholesterol with pills? Her doctor seems to have an attitude that she, "Looks good on paper for a woman her age,” so is inclined not to mess with things too much.

Pancreatitis definitely elevates blood sugars, so the elevation in HbA1c was expected. Your mother is at high risk to progressing towards DM, if there was sufficient damage to pancreas, so diet and lifestyle changes is important.

The new guidelines for statin were recently released and based on those criteria she may benefit from statin. I agree with your physician—since we treat patients not numbers. If her triglycerides are elevated that could risk another pancreatitis episode, so definitely close monitoring of the lipids is needed. If her parameters worsen despite lifestyle changes, then statin may be re-considered.

calinda: I am not on medication for diabetes mellitus (DM) at this time. I always have higher readings in the morning (130 to 160) than in the evening (100 to 110). Do you have any suggestions? Also, are there any drugs that may increase blood sugar, such as Coumadin® (warfarin) or Zocor® (simvastatin)?

Seenia_Peechakara,_MD: Higher morning readings are a known phenomenon for diabetes—it is called dawn phenomenon. Some measures like weight loss, and cutting out on late night snacking would help. Drugs like metformin also help in this regard. Coumadin® and Zocor® are known to cause hyperglycemia, but if they are necessary part of your regimen, then you cannot avoid those.

harkness: My last two fasting blood sugars have been 104. Could that be attributed to my medication Lipitor® (atorvastatin calcium)?

Seenia_Peechakara,_MD: It is hard to say from just two readings. The data linking statins like Lipitor® and hyperglycemia is somewhat conflicting right now. Your fasting blood sugar of 104 suggests prediabetes and calls for HbA1c check (three-month blood sugar average) in addition to lifestyle modifications to prevent progression to diabetes—if you are not currently a diabetic.

Jay: Would you explain HbA1c?

Seenia_Peechakara,_MD: HbA1c is a blood test. It is the average blood sugar over the last three months. It is reported as a percent. The ideal HbA1c for a diabetic person is 6.5 to 7 percent. HbA1c  of 7 percent suggests a person’s blood sugar has been running on average in the 100 to 150 range.

clearsailing: How often should A1C blood test be done? Every three to seven years? For diabetics, does it make a difference if you see your family doctor vs. an endocrinologist?

Seenia_Peechakara,_MD: Once every three months for diabetics on treatment, and also if any active changes are being made to the regimen. For a well-controlled patient with no active medication changes, once every six months is adequate. Diabetes mellitus is a chronic disease, and, therefore, is managed by quite a few primary care doctors. They usually refer to endocrinologists if control is not adequate. It usually comes down to the experience and comfort level of the primary care physician with respect to Diabetes management.


LucyintheSkies: My father was 50 years old when he was diagnosed with diabetes, but he was obese, ate a poor diet and had high blood pressure. I know diabetes is hereditary, but, if I eliminate risk factors and have a healthy lifestyle, can I truly avoid the disease?

Seenia_Peechakara,_MD: You are correct, diabetes is hereditary. Modifying risk factors can certainly help prevent or delay the onset. Whether it can be completely avoided depends on how strong the genetic factor is and how well the risk factors are modified.

madeline: If you are told you are prediabetic, will this turn into diabetes, or are there ways you can stop it from progressing? If I make an effort to change my lifestyle, will it make a difference, or is diabetes inevitable? My mom has type 2 diabetes (DM), so there is a family history.

Seenia_Peechakara,_MD: The rate of progression from prediabetes to diabetes is approximately 20 percent at five years, i.e., 20 out of 100 patients with prediabetes would convert to diabetes in the next five years. This is statistical data, so these outcomes are not inevitable. Aggressive lifestyle modification with proper diet, exercise, weight loss and medications, like metformin, can delay or even prevent DM. Genetic predisposition is something one cannot modify, but the risk factors can be modified.


skindr: Taking Starlix® (nateglinide) 60 mg three times a day and metformin one pill in the morning and two pills in the evening. My morning glucose averages 150 to 160. My A1c was recently 7.4. I am a 67-year-old white male. Is this an acceptable range, or is tighter control needed? Do you have any recommendations?

Seenia_Peechakara,_MD: An A1c of 7 would be the goal. You should focus on getting your morning blood sugars to would help towards the goal. For your age group, it is  preferable to have morning fasting blood sugar levels in the 100 to 130 range. The various ways to achieve this would be weight loss, cutting out late night snacks (if applicable), and adding GLP1 analogs like Victoza® (liraglutide [rDNA]) or Byetta® (exenatide).

applepie: Is there a preferred time of day for injecting Levemir® (insulin detemir [rNDA origin] injection)? People have told me to take it in the morning, and others have said take it at bedtime. Regarding my other three oral diabetic medications, should they be taken all at once or separately at spaced out times throughout the day?

Seenia_Peechakara,_MD: Levemir® is usually once a day, and it doesn’t matter if it is taken in the morning or evening. If morning blood sugars are not well controlled, then bedtime would be a better choice. Regarding your oral medications, it depends on what pills you are taking. Some need to be spread out while other can be taken together.

kellers22: What is the function of metformin in the control of diabetes?

Seenia_Peechakara,_MD: Metformin is an insulin sensitizer. It makes the endogenous insulin (your own insulin) work more efficiently at the cellular level. Metformin helps the muscles take up the glucose from your blood better, thereby reducing your overall blood glucose.

Diabetes and Nutrition

sandylee323: I am confused about carbohydrates and fiber. If beans, oatmeal and bananas are high in carbohydrates, should we still eat them for the fiber? How do we find a registered nutritionist to help us with our meal planning? I am pre-diabetic, and want to learn all I can.

You can certainly make an appointment at Cleveland Clinic’s Diabetes Center. We have certified diabetes educators and nutritionists who can help with meal planning and education. Foods high in carbohydrates have a better glycemic index and slow the absorption of glucose. Portion control will be the key with foods rich in carbohydrates.

Lacey: If vitamin B12 deficiency is suspected, can an over-the-counter supplement be taken and how much

Seenia_Peechakara,_MD : It depends on how bad the deficiency is, but usually prescription strengths of vitamin B12 are needed.

msnyde03: Can you talk a little about the sugar in alcohol and the effect it has on your blood sugar?

Seenia_Peechakara,_MD: Alcohol can make your sugars lower—especially if the alcohol consumption was without any accompanying carbohydrates. This is because the alcohol affects the liver, which is the glucose store in your body. At the same time an alcoholic beverage like beer, which is high in calories, would transiently make your sugars shoot up.

ppr: What effect does salt have on glucose?

Seenia_Peechakara,_MD: No direct effect—except that both taste good, and in excess one causes high blood pressure (salt) and other causes diabetes (sugar). Both together could contribute to heart disease.

Diabetes and Supplements

ohmy: Are there any recommended supplements that would be of benefit to most patients with both diabetes and heart disease?

Seenia_Peechakara,_MD: Aspirin is proven to be helpful, but talk to your doctor if you are a candidate for it. As far as natural supplements, there is no definite data.

jellybeans: How good are mail order supplements for diabetes?

Seenia_Peechakara,_MD: There are no studies that would support or negate these. They are not FDA-regulated supplements, so the contents would be anyone's guess. The only supplement studied, which has shown some improvement for diabetes, is cinnamon and garlic

Exercise, Weight Loss and Gastric Bypass

pburke: I am 51 years old now, and was diagnosed with type 1 diabetes mellitus (DM) when I was 49 years old. Between menopause and diabetes, I cannot seem to lose weight. Do you have any suggestions?

Seenia_Peechakara,_MD: Weight management is multifactorial. In addition to diet and exercise, restricting your carbohydrate intake would help. Other endocrine disorders like thyroid dysfunction may need to be checked. A consultation with your physician or a dietician can help you. Cleveland Clinic’s Diabetes Center offers weight loss programs supervised by physicians as well.

jko: Is it true that type 2 diabetes mellitus (DM) is sometimes resolved in people who have had gastric bypass surgery?

Seenia_Peechakara,_MD: Yes, it is true, but not in everybody though. It depends on what degree of diabetes these patients had to start with prior to surgery.

camerashy: With regard to exercise, which is better in helping to reduce insulin resistance or to help transport it into muscles—aerobic or anaerobic?

Seenia_Peechakara,_MD: Aerobic exercise is best.


Moderator: I am sorry to say that we are at the end of our chat. We appreciate your participation and hope you will join us for other chat topics in the future. Thank you, Dr. Seenia Peechakara, for sharing your expertise and answering questions today about.

Seenia_Peechakara,_MD: Thank you very much. The questions were excellent!

For Appointments

To make an appointment with Dr. Seenia Peechakara, 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

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On Diabetes Mellitus

November is Diabetes Awareness Month! Our calendar features diabetes-related events happening throughout the month of November, as well as helpful tips, tools, and resources to help you or your loved ones manage the disease.

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On Cleveland Clinic

Cleveland Clinic’s Diabetes Center provides patients access to a multidisciplinary team, including endocrinologists, diabetic educators, dieticians and a nurse practitioner. The goal of Cleveland Clinic’s Diabetes Center is to encourage both Diabetes Mellitus Type 1 and Type 2 patients to receive early specialty care and education—getting them on the right track with their diabetes management before returning them to their primary care physicians for ongoing management. The Diabetes Center offers both individual and group diabetes education classes year round for patients and their families. Another convenience offered is retinal eye screenings on-site to provide screening for diabetic eye conditions.

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. 

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