Type 2 Diabetes: Are You at Risk? With Dr. Shirisha Avadhanula

Podcast Transcript

Deanna Pogorelc:

Welcome to the Health Essentials Podcast, brought to you by Cleveland Clinic. I'm your host, Deanna Pogorelc.

More than 34 million Americans live with diabetes and millions more have pre-diabetes, but many of them may not even realize it. Understanding your diabetes risk is important for your long-term health. It's also even more important against the backdrop of the COVID-19 pandemic, since diabetes is a known risk factor for severe complications from COVID-19. To help you better understand diabetes and how to overcome hurdles in preventing and managing diabetes. We have Dr. Shirisha Avadhanula. She's an endocrinologist here at Cleveland Clinic. Welcome to the podcast. Thanks for being here.

Dr. Avadhanula:

Thank you for having me, Deanna.

Deanna Pogorelc:

And to our listeners, please remember this is for informational purposes only and is not intended to replace your own healthcare providers advice.

So I thought it might be helpful to start a little bit by talking about what diabetes is and what's happening in someone's body as they develop diabetes.

Dr. Avadhanula:

So, that's a great place to start. Diabetes is a metabolic and endocrine dysfunction, and it's a state in which there's an excessive amount of sugar that accumulates in your blood. This sugar can then deposit into small blood vessels in the body and can eventually potentially cause organ dysfunction.

Deanna Pogorelc:

Does that happen over time or how long does it take?

Dr. Avadhanula:

It can happen over time. Generally, there's a state called prediabetes, which is something that occurs usually before the state of developing overt type 2 diabetes. There can be things that we can do to prevent the progression from prediabetes to overt type 2 diabetes. But generally, yes, this is more of an elongated process that happens over time.

Deanna Pogorelc:

And for this conversation, can we distinguish between type one and type 2 diabetes?

Dr. Avadhanula:

Yeah. So I think in order for us to go into the different kind of broader categories of diabetes, let's step back a little bit and talk about the normal process of digestion and insulin secretion. So I'll just use myself as an example here. This morning, I ate two pieces of toast. That carbohydrate rich meal, as it goes through the process of digestion, it breaks down into sugar. And when sugar reaches the bloodstream, there is a stimulation for something called insulin to be secreted. Insulin is a hormone that is secreted from the beta cells of the pancreas. When insulin is secreted, it allows sugar from the bloodstream to go into your cells. So think about insulin as if it's a key and think about the cells of your body having a door, and they're all locked. So insulin unlocks those cellular doors and it allows glucose to enter the cell, and so we use this glucose to fuel our body as an energy source.

So broadly speaking, there are two classes of diabetes. We talk about type one diabetes, which is also known as autoimmune diabetes. And we have type 2 diabetes. Type one diabetes is generally diagnosed earlier in life, and it's also known as autoimmune. When I talk about autoimmune, what we mean by that is, say for example, you're infected by a virus or I'm infected by a virus. What happens in my body is that we mount an immune response. When you have an autoimmune disease, what happens is your body actually mounts an immune response to your own organs. So in type one diabetes, your body mounts an immune response to the cells of the pancreas that produce insulin and therefore you have no insulin production. So these patients are rendered what we call insulin dependent.

Type 2 diabetes, on the other hand, the major premise really is insulin resistance. And so what happens is that most of these patients do secrete insulin, but their cells are resistant to the effects of insulin. So they're not able to take up that sugar into their cells effectively.

Deanna Pogorelc:

So what is the relationship between type 2 diabetes and obesity that we hear about?

Dr. Avadhanula:

There is a strong relationship between type 2 diabetes and obesity. The first is correlational. We've seen the prevalence of obesity go up throughout the years and, to mirror that, we've also seen the prevalence of diabetes going up throughout the years. The second has to do with what I was alluding to earlier and that's insulin resistance. So as we gain more weight, our cells become more and more resistant to the effects of insulin. And then unfortunately we can develop type 2 diabetes.

Deanna Pogorelc:

What are some of the other risk factors for type 2 diabetes?

Dr. Avadhanula:

There are many risk factors when we talk about type 2 diabetes. Things like women who suffer from polycystic ovarian syndrome tend to have a higher insulin resistance and they tend to develop type 2 diabetes. Women who become pregnant and develop gestational diabetes. People who have family history of type 2 diabetes and also searching certain racial and ethnic groups can also be predisposed to developing type 2 diabetes.

Deanna Pogorelc:

How might someone know that they're developing diabetes or prediabetes?

Dr. Avadhanula:

The most common symptom of all is no symptoms at all. When a patient comes to our office, they often come to us with a blood test called the hemoglobin A1C level. This is a standard non-fasting blood test that we can do either in the office or in the lab, and this tells us a three month average of your blood sugar. So a hemoglobin A1C, if the percentage is over 6.5, this diagnoses somebody with diabetes. Sometimes patients will come to us with things like increased thirst or increased urination, but these are a little bit less common. Even more rarely people can come to us with things like weight loss and blurry vision if the diabetes has progressed. But like I said, the most common symptom really is no symptom at all.

Deanna Pogorelc:

So is that blood test something that people should be getting regularly or after a certain age?

Dr. Avadhanula:

That's a great question. The screening of type 2 diabetes is different by different guidelines, but everybody agrees that type 2 diabetes should be screened in patients over the age of 45 in anybody who's overweight or obese. Patients who are over the age of 45 with an additional risk factor, the things we were talking about earlier, so if you have a diagnosis of polycystic ovarian syndrome, something like a history of gestational diabetes or a family history, for example, you should realistically be tested for type 2 diabetes.

Deanna Pogorelc:

Why is that diagnosing so important? Does diabetes always need treatment or why should people really be aware of their risk?

Dr. Avadhanula:

It's important for our patients to be aware of type 2 diabetes, because it can lead to some really serious complications in the body. Serious complications can be things like amputations, blindness, heart attacks and even strokes. So it's very important for the general public to have a baseline knowledge of what type 2 diabetes is and its potential complications.

Deanna Pogorelc:

And then does it always need to be treated?

Dr. Avadhanula:

Yeah. So, when somebody comes to us with diabetes, oftentimes we'll put them on oral medications. If their hemoglobin A1C is high enough, for example if it's over a percentage of nine, we tend to treat them with insulin. I just want to say though that one of the most common misconceptions when a patient comes to my office is that they think because they're on insulin, this is a life sentence to insulin. But this is absolutely not true. Our major goal for a type 2 diabetic who has a normal functioning pancreas that's producing insulin is to get them off insulin as efficiently and effectively as possible. So we treat patients with oral medications, insulin when needed, but really our major goal is to get patients off insulin. Another really common misconception I see is that when patients are diagnosed with type 2 diabetes, they think this is a life sentence and that this is irreversible. But again, this is absolutely not true. With good care and good follow-up with your care team, you can achieve diabetic remission.

Deanna Pogorelc:

Aside from insulin, are there other medications that you have in your toolbox for treating people with type 2 diabetes?

Dr. Avadhanula:

There are multiple medications that we can use in the treatment of type 2 diabetes. So generally when a patient comes to us, they come to us and we start them on oral medications, our treatment of choice is usually Metformin if there's no other contraindications. As things progress and we get to know our patients better, we have an entire toolbox of medications that we can use. For example, if I have a patient who is trying to lose weight, I can choose a medication that will help that patient lose weight, as well as control their blood sugar numbers. So there's a lot of things and a lot of different things to take into consideration when reaching into our toolkit of medications to use for our patients with type 2 diabetes.

Deanna Pogorelc:

What do we know about diabetes in terms of the COVID-19 pandemic? Why is it a risk factor for COVID-19 and how does that work?

Dr. Avadhanula:

So, unfortunately, throughout the course of the pandemic, we have really seen how type 2 diabetes can be very, very serious. Patients with type 2 diabetes who are infected with the Coronavirus tend to have more serious complications when they are infected. In fact, there was a study that was done that showed that patients who had a history of type 2 diabetes that were infected with Coronavirus were seven times more likely to die than patients without serious underlying comorbid conditions. So we know that patients with type 2 diabetes and patients with obesity as well also tend to suffer a more severe illness if they are in fact infected with Coronavirus.

Deanna Pogorelc:

Okay. So as we start seeing these vaccines roll out in our communities, should people who have type 2 diabetes or obesity consider getting those vaccines?

Dr. Avadhanula:

That's one thing I will say absolutely unequivocally, yes. Once these vaccines are available to you, I would encourage every patient, whether you have type 2 diabetes or not, get vaccinated.

Deanna Pogorelc:

Great. So when it comes to managing diabetes and bringing down some of those risks that we talked about, both longterm and related to COVID-19, what are the goals of treatment? And what's the best way to measure how successful someone is managing their blood sugar?

Dr. Avadhanula:

So the best thing to do really is to get somebody's blood sugar akin to a normal blood sugar. We usually monitor progress with things like blood sugar logs when we see our patients in the office, but we also monitor progression with the hemoglobin A1C, which is the lab test that I was mentioning earlier. We like to see a downward trend of the hemoglobin A1C, and eventually we love to see it when our patients achieve remission, which is a hemoglobin A1C of under 6.5.

Deanna Pogorelc:

In your practice, what are some of the hurdles that you see that prevent people from getting there?

Dr. Avadhanula:

In my practice, I predominantly serve what is considered an underserved community of patients. Cost burden is a major issue. When Dr. Banting and Dr. Best sold their insulin patent, they sold it for a dollar. And now just a month's worth of insulin can cost hundreds of dollars.

Another big problem is health literacy. So within our communities, really the onus is on us as a medical community to be out there educating our patients and the public at large, which really isn't happening. So I think it's not so much in the care. We are delivering it. We have to learn to change the way in which we deliver that care. I really think we do an excellent job in educating ourselves, but when it comes to educating our patients, we really tend to come up short. The other problem is access to healthcare in general is limited within our communities. There's basically one endocrinologist for every five to six thousand patients with diabetes in this country. So most patients with diabetes will never have the opportunity to speak with a specialist altogether.

Deanna Pogorelc:

Okay. So can we talk about some of the resources that are available to help people overcome some of these hurdles? For example, if someone doesn't have easy access to fresh and healthy food, but maybe there's a fast food restaurant right there on the corner, what are some of the things they can do or some of their resources that they can find?

Dr. Avadhanula:

Yeah. And I think this is definitely the most relevant question in medicine right now, and a pretty difficult one to answer because it's so complicated. I wish I could give you a clear and concise kind of answer to this, but going back, the reasons for disparity in itself are very complex and they touch on things like social, economic and historical factors. Also, the other thing is that it's just not diabetes. We know that historically underserved groups, they tend to fare worse when talking about outcomes of nearly any chronic disease ranging from cancer to cardiovascular disease and even to infant mortality.

For one, the density of hospitals, clinics or providers tend to be lower in non-affluent areas. And the second thing is that private insurance often affords far more effective follow-up and newer medications than public insurance plans do, that most of my patients have. Sometimes patients will have insurance, but they can't afford their medications, and it's not an uncommon thing that I hear in my practice. "I could have eaten or I could afforded my medications." And this is unfortunately not something that is uncommon to me. Also, when there's a copay to see your doctor, there's also other factors to consider like transportation costs. There's truth in the saying, "An ounce of prevention is worth a pound of cure." So when we talk about obesity and diabetes, having a healthy diet is a super key component in the management of these things. But for many of my patients, like millions of Americans, accessibility to healthy food is simply just not an option.

Many of these families live in low income neighborhoods, and I'm sure we've all heard of the term food desert. I think it's something that we're all familiar with, but it's been coined to describe neighborhoods where accessibility to things like fresh fruits, fresh vegetables lack accessibility. And patients will literally have to make a trip for several miles just to get access to healthy foods as an alternative to what they're finding at, for example, The Dollar King, the processed foods that they're finding at the corner store.

We also know that from decades of research, there's at least some level of implicit bias against minority patients from providers in our healthcare system. And there have been historical reasons for minority communities to really lack trust in their providers, as well. So we need to do a better job of having a more equitable and culturally competent intervention that is meaningful for our patients from all of these different kind of backgrounds.

So when we talk really about closing the gaps in our healthcare, I think it's important to take a step back and take a look at all of these very different complexities that are involved in shaping our healthcare system. There have been some interventions. There’s policies that have been enacted at the national level, at the local level, at the state level to improve for food environments. And I'm certainly not saying that if you put a fresh food store in an underserved neighborhood, America's food problem will be solved. I'm certainly not saying that. It's not so simple, but there are things that are being done.

Things like online grocery shopping, that has become a great option for patients. So if they have access to the internet or to a smartphone, ordering online groceries may be a good option for our patients. And there's also been some state financial initiatives to finance fresh food products in the last couple of years, as we've become more and more aware of these issues. But again, really the onus is on us as a medical community to educate ourselves about all of these complex issues and also educate our patients and provide them with the resources that they need.

Deanna Pogorelc:

Absolutely. You mentioned access to healthcare, and so I wanted to ask, what about people who have trouble getting to appointments? Maybe they don't have reliable transportation but really need that support to stay on track. Is there anything that those folks can do?

Dr. Avadhanula:

That's a great question. And here, I'm happy to say that we offer virtual visits. So for patients that can't come in to their appointment for transportation reasons, or maybe they're not accessible in terms of location or distance, we do offer virtual visits for our patients. So they're able to see us in the comfort of their own home and a lot of our patients have really found benefit in this.

Deanna Pogorelc:

Great. You touched a little bit on money and affordability. Is there anything being done to help make medicines more affordable?

Dr. Avadhanula:

Yeah. There are some patient assistance programs. There's five insurance plans that are nationally working with Centers for Medicaid and Medicare to participate in a $35 a month insulin program nationally for the next five years. We're far away from where we should be, but at the very least there's some prospect.

Deanna Pogorelc:

Okay. For someone who maybe is a little bit overweight or has been diagnosed with prediabetes, what steps can they take now to change the course?

Dr. Avadhanula:

When being diagnosed with prediabetes, this is absolutely a reversible process. This doesn't mean that you will develop overt type 2 diabetes. There are things you can do to reduce your risk. The first thing is having a good diet and routinely exercising. There was a study that was done a couple of years ago that compared lifestyle intervention with some of our really good standard diabetic treatment. And actually lifestyle intervention was superior to some of our standard diabetic treatment for the progression of prediabetes to type 2 diabetes. I would say that early intervention in prediabetes is absolutely key to success.

Deanna Pogorelc:

So I'm guessing a lot of people would like to know, what's the best diet for losing weight?

Dr. Avadhanula:

This is such a common question that I get asked. People ask me all the time what do you think is the best diet for me to lose weight? And the truth is there was a study that was done a couple of years ago, and it compared all of these popular diets, and what it showed was that all of the patients lost exactly the same amount of weight. So there is no diet or one diet I should say that is better than the other. Really, the most important thing is adherence to whatever diet you pick. If you like, for example, intermittent fasting, if you think that works in your lifestyle, then do intermittent fasting. But for example, if you choose to do something else like low carb or a keto diet, and you feel like it's just not working for you, then don't do it.

The key to any diet or any lifestyle modification truly is adherence. And I know I said this before that consistency is key, but there's a scientific reason behind this. So when we're trying to lose weight, when we've lost the weight, our body goes into a period where it thinks that we're starving. So it secretes a lot of different counter regulatory hormones to increase our hunger and decrease our satiety.

We have something in our bodies called a metabolic set point, and everybody is set at this point. This metabolic set point doesn't change for three to five years. So these hormones will continue to secrete for three to five years when you're dieting, which is why it's really important to stick to a diet that you're able to be consistent with at least for five years, in order for you to be successful in your weight loss journey.

Deanna Pogorelc:

If someone has tried a lot of different diets and just is really struggling to lose weight with the diet alone, are there other things that you can do to help them?

Dr. Avadhanula:

There are. There are different interventions for patients who are trying to lose weight. So if a patient, for example, has done a diet, they have done exercise routinely and they come to us after three or six months and they say, "I've done all of these things, but I still can't seem to lose weight," at that point, we would introduce medical weight loss management. We often offer these patients weight loss medications. I'm not saying that this is a magic pill. There's no such thing as a magic solution, but weight loss medications can be a good option for patients provided that they have no contraindications.

There's no medication that doesn't have a side effect. So some of these medications do have a side effect, but generally speaking, they are well tolerated. For patients who have a BMI of over 40, at that point we would consider something called bariatric surgery and we would refer them to the Bariatric Institute, where they would get evaluated. Additionally, patients who have a BMI above 35 and they have additional comorbid conditions, things like type 2 diabetes, things like sleep apnea, or even polycystic ovarian syndrome, we send them to the Bariatric Institute for evaluation.

Deanna Pogorelc:

Great. Is there anything we haven't talked about yet that you'd like to mention or any last takeaways you want to leave our listeners with?

Dr. Avadhanula:

Just seeking out the knowledge and listening to these podcasts and relying on reliable sources of information is a win in itself. If I have in any way contributed to your body of knowledge, I'm grateful to have been a part of your journey, but I would really encourage you to continue to empower yourself with the educational tools that you need to live your best possible life. Thank you for having me.

Deanna Pogorelc:

Well, thank you so much for being here. It's been great. And for our listeners, if you'd like to learn more about diabetes care at Cleveland Clinic, please visit clevelandclinic.org/endocrinology, or call (216) 444-6568. To hear more interviews with our Cleveland Clinic experts, visit clevelandclinic.org/hepodcast or subscribe wherever you're listening. You can also follow us at Cleveland Clinic on Facebook, Twitter, and Instagram for more health tips, news and information. Thanks for joining us.