Diabetes Patient Basics
Diabetes Patient Basics
Anne Peters, MD, FACP, CDE (Professor and Director of Clinical Diabetes Programs, USC Keck School of Medicine) gives expert video advice on: Does taking additional insulin correct a high blood sugar level?; Why is my blood pressure important if I have diabetes?; What are the most common causes of death for people with diabetes? and more...
What questions should I ask my doctor first when I am diagnosed with diabetes?
I think one of the most important things that someone can learn early is what type of diabetes they have, whether it's type 1 or type 2. The problem is that many physicians aren't going to be able to distinguish between type 1 and type 2 diabetes, particularly not early on. So, if you are someone who has no family history of diabetes, you're lean, you're young and look for all the world like someone with type 1 diabetes, then that's probably what you have. You need to ask your doctor, "Is this type 1 or type 2, and why?" Then you need to ask your doctor about what treatments you're going to have. I think people also need to always ask if they can see a dietician, because when you first get diabetes, you need to see a dietician, and a lot of physicians may not make that referral. So, I think that, from the get-go, knowing what type you have (or if there's going to be some sort of blood test or something done to figure out which type you have), and then helping your treatment mesh with your diet, from the beginning; that will make your life better.
What's the first thing my doctor will do if she suspects I have diabetes?
If your doctor thinks you have diabetes, the very first test should be a fasting blood sugar test, which basically means that they draw your blood after you haven't eaten overnight, for ten to twelve hours. You can have water and they look to see if its elevated. If it's above one hundred, it's abnormal, and if its about one hundred and twenty-six its diabetes.
How will diabetes and its treatment impact my loved ones?
When people get diabetes, they often have family members who've had diabetes and in many cases they've seen family members go blind or go on dialysis or have just horrible deaths and so there's an element of fear in both the patient and also in the family members. I think that like all things, there's all sorts of ways to deal with fear the least productive way to deal with diabetes though, is denial. The best way is to take the family together and say let's deal with this as a unit, let's figure out how to cook food for all of us that's healthier, let's figure out a way that we can all change our exercise patterns. I think often people with diabetes and their families need to see a therapist. They may need to deal with the depression that comes with getting this diagnosis. Many people with diabetes need to take antidepressants for depression. There's a lot that needs to go on with a family and the individual to psychologically accomodate to this, but once people do, it just becomes part of who they are, just like anything else. A normal adjustment to a stressful situation that can end up really happily.
What do I do if I have nausea or vomiting and I'm a diabetic?
When people with diabetes develop nausea and vomiting, it can be actually quite serious because, if you've given insulin or you've taken an oral medication that lowers your blood sugar levels and you can't eat or drink, you can get very dehydrated and your blood sugar levels can fall. So, in many cases, people with the symptoms of nausea and vomiting will need to go to the emergency room. But the caveat is if you can call your health care team, they can advise you what to do. They can teach you about how to take care of your diabetes when you're sick. They can give you medication to stop the vomiting, then you might not have to go to the emergency room. But it's the kind of situation where many people with diabetes need to contact their physician and then get some assistance. We always give our patients sick day rules so they know what to do when they're sick and I try to prepare people but when someone's sick who has diabetes like that I just want them to call me because I want to know so I can help them through it. It's one of those things you don't want to mess around with but you really want to see the person and do what you can to get them better.
Does taking additional insulin correct a high blood sugar level?
Giving insulin is an incredible art because you're trying to be a pancreas; you're trying to be an internal organ and you're giving it externally. So, if your blood sugar is three hundred, which is way too high as you're supposed to be a hundred (a hundred's normal) and you give a dose of, say, four units of insulin (what we call a correction) to bring it down to a hundred, and you check it an hour later and it's still high, what do you do? Well, what you don't want to do at that moment is give more insulin because we call that "insulin stacking". If you give insulin too soon after the last dose, the insulin can build up in your body and cause a low blood sugar reaction. So, we have people wait for several hours in between doses so that then there's not that risk of a low blood sugar. One of the things that a pump, an insulin pump does, is it actually calculates what we call "insulin on board". So, say you wait for two hours, you check again and you're still high, it will calculate how much of the last dose is still in your body and let you give a little bit more so you come to the right balance. Technology helps us answer that question better, but the rule of thumb is don't give insulin more often than every three to four hours so you don't stack the insulin and cause a low blood sugar reaction.
What is "diabetic neuropathy"?
Diabetic neuropathy means that the nerves are damaged due to high blood sugar levels and it takes on a whole bunch of different forms. The most classic kind is what we call peripheral neuropathy, which is a kind of neuropathy that starts in the tip of the toes. Actually it is on both sides, not just one. It often starts out as a tingling as if the nerves are being irritated. That tingling can eventually become really very bad pain and then eventually that pain goes away and the foot becomes (or both feet) become numb. When those feet become numb it means they can't feel either say a rock or a piece of glass in the bottom of the foot. People often become unsteady because they can't feel where their feet are; they lose what we call peripheral perception or the ability to know where your body parts are in space and that neuropathy can go up your legs you can also get it of your fingers and arms. But the neuropathy for diabetes is not just of those peripheral nerves it is many other places as well. it can affect the nerves that go to the stomach so people get something called gastroparesis which means their stomach doesn't empty normally so they get full and bloated and nauseated. It can cause the bladder to not also empty normally so people can get bladder problems. It can cause the intestines to get too much bacteria so people get constipation and diarrhea. It can cause the sexual organs not to work right so it causes a lot of erectile dysfunction in men and probably causes difficulties in women as well.There is effects on blood pressure as well. It can cause blood pressure to fall abnormally low as well as be too high. And so basically everything in the body that is controlled by nerves, which is pretty much everything in the body, can be affected by diabetic neuropathy. It sounds grim, which it is except that A) we can prevent it and B) if you know that you are at risk for it and we diagnose it then we can offer specific treatments say, for gastroparesis or the bladder problems so like everything, knowing more about it is helpful.
Why does diabetes increase "fatty plaque"?
Diabetes causes a two- to-fourfold increase in the risk of heart disease and stroke. And the reason it does this probably has many different causes. One is because diabetes can cause high blood pressure. But also, inside the artery there's all of these sort of cells and markers and cholesterol. Blood sugar is sort of like taking a smooth surface, say, Teflon, and making it like Velcro. And so blood sugar takes the lining of the arteries and makes them stickier, and it also makes the little particles, the inflammatory cells, the cholesterol, stickier. So when you have diabetes, that sugar level in your blood makes all of the particles that lead to clogging of the arteries just stick more. And that increased stickiness is why people with diabetes have higher rates of heart disease. It's even more complicated than that, though, because people with Type 2 diabetes have other abnormalities. Their liver makes embolic cholesterol particles, their blood pressure's higher, there are a lot of other problems in Type 2 that makes them an even higher risk. But sugar itself I think is taking the lining of the arteries from Teflon to Velcro so stuff sticks to it, and the stuff that sticks to it causes the plaque that leads to heart attack and stroke.
Why is my blood pressure important if I have diabetes?
Blood pressure control is incredibly important for people with diabetes, for a variety of reasons. First of all, people with type 2 diabetes tend to have hypertension. Patients with type 1 diabetes may not have hypertension, but if their blood sugar goes up, it needs to also be treated. The reason for treating blood pressure is as follows. People with diabetes tend to get heart disease at much higher rates than people who don't, and treating hypertension lowers risks of heart disease. In people with diabetes, treating high blood pressure helps prevent blindness because it lowers the pressure on the back of the eyes. It helps prevent kidney disease, particularly if people have some kidney damage. As a result, hypertension treatment is just vitally important. We actually have lower standards regarding blood pressure in diabetes patients. We say the blood pressure should be less than 130/80 in patients with diabetes, which is a different treatment target than people without, because we really think that having a normal blood pressure can make a big difference. Also really, just in terms of overall health, I think it's an important thing to do.
Why is my cholesterol important if I have diabetes?
Treating lipid, or cholesterol levels in diabetes is very important, because people with diabetes have very high rates of heart disease and stroke. And it's not so much that bad cholesterol levels are high in people with diabetes, it's the good cholesterol, or HDL levels are too low, and triglyciride levels, which are a measure of fat in the blood, are too high. But it's not the triglyciride levels that hurt you. It's really the fact that the good cholesterol is too low, and the bad cholesterol, or LDL cholesterol, may be a little bit high. But what it is, is abnormal. Those cholesterol particles are stickier, because of the presence of high blood sugar levels. And so people with Type 2 diabetes and Type 1, but mostly Type 2, have this very accelerated rate of heart disease. So we say, people with Type 2 diabetes, and include Type 1's in this too, 'cause we think it's also important, really need to have their cholesterol, their bad cholesterol, treated to be less than a hundred. And I really want people to know their LDL cholesterol. A lot of people know total, but I don't care about total. Total is the sum of the bad and the good. If your bad isn't very high and your good is too low, your total could be artificially low. So people need to know what is their LDL or bad cholesterol level, and it needs to be treated to less than a hundred. And if people have had heart disease already, it should be treated to less than seventy. So treatment of cholesterol levels is very important, and is actually different than in patients without diabetes.
What is a "triglyceride level" and why is it important if I have diabetes?
A triglyceride level is a marker for abnormal cholesterol particles. If your triglyceride level is high, it means that the pathway through which you metabolise your bad cholesterol levels is not normal, so it means your bad cholesterol is stickier than in someone without diabetes. So, a triglyceride level that's elevated is a marker for an increased risk for heart disease and building up plaque in the arteries, but in itself isn't going to hurt you; it's what it means in terms of the entire set of features for heart disease risk in diabetes.
What infections am I prone to if I have diabetes?
In my experience people with diabetes whose blood sugars are controlled don't tend to get infections at any higher rate then anyone else, but if blood sugar levels are high even a little bit, there are a variety of different kinds of infections that can occur. Common infections I see, especially in women, are urinary tract infections and yeast infections. I can almost tell a young woman's blood sugar levels by how often they're having yeast infections. I think yeast like that sugary stuff that grows down there when blood sugar levels are high. The same thing goes for other kinds of fungus; foot fungus (the thickening of the nails) is really common in people with diabetes. I think fungus likes sugar. In people whose blood sugar levels are high there are important infections that they can get, for instance, sometimes what seems like a little tiny infection of the skin can end up going down to the bone, and become what we call osteomyelitis, or an infection of the bone. People with diabetes can get other infections, of say their sinuses or their ears; sort of rare uncommon infections. The vast majority of those people have very poorly controlled diabetes. In most cases good control of diabetes helps control the effect of the high risks of infection.
How could having an infection worsen my glucose control?
When people with diabetes, either type 1 or type 2, develop an infection, they get what we call 'Insulin resistance'. 'Insulin resistance' means that the body doesn't respond as well as it should to circulating insulin levels. So, say somebody with type 1 diabetes gets a head cold. Their blood sugar levels which may normally be a hundred may suddenly become 200 even though they have the same dose of insulin, so they are resistant. An infection makes you resistant to whatever your usual treatment is. As a result, many of my patients can tell when they are getting sick, because their sugar levels go up. Then, as long as they are sick, their sugar levels will stay high, and then they'll come down back to normal once the infection clears. In patients who aren't on insulin as often, I have to increase their insulin doses in order to bring their blood sugar levels back down. It's something that happens in all of us, but we, those without diabetes who get infections, don't know that we need to make more insulin, because our pancreases do it without thinking about it. However, in diabetes we just need to increase the medication to do with it.
What is an "insulin reaction" or "hypoglycemia"?
An insulin reaction, which is also called hypoglycaemia, basically means that your body has too much insulin, so too much sugar goes into the cells, and then the blood sugar to your brain starts to fall. Now, all of us have had a hypoglycaemic reaction; say you eat a doughnut and then two hours later you're trying to focus but you just feel all shaky and jittery and you've got to eat; that's a blood sugar reaction. That means that your blood sugar levels are falling. Your blood sugar level may not get too low, but your sugar level is falling and you feel it. We call that the adrenergic signs of a low blood sugar reaction; you feel shaky, sweaty, hungry, weak, tremulous, all of that happens. If you eat something, if you eat sugar right then, your blood sugar level will come back up to normal and you're fine.
What happens when a hypoglycemic reaction gets out of control?
The problem is is in diabetes sometimes the insulin dose is so much that you don't have time to treat it or what happens is you're not carrying sugar with you, which people with diabetes all should do. Or, in people who have had diabetes for long enough they lose warning signs like that, and so what happens is the blood sugar level keeps getting lower and lower and lower, so instead of being a hundred, it becomes seventy, then it becomes fifty. And below fifty people tend to lose the ability to think and see normally, and eventually they'll lose consciousness, and that's what we call a sever blood sugar reaction, it's when you are, lost consciousness and someone else has to revive you, they either have to call the paramedics or give you an injection of something called Glucagon, and those are really awful reaction for the people who have them. We try really hard adjust the insulin, to do what we can to prevent those reactions, but they still do occur. So when those happen, if someone's prepared and has Glucagon that can be given, sometimes patients will have seizures at that point, not everybody but some people will, and like all seizures they tend to pass, but again, the paramedics generally come, patients are treated and then they'll get better. So they're disturbing events and everybody who's on insulin or anything that can cause their blood sugars to go too low, some of the oral agents should carry fast acting sugar with them, say Glucose tablets or Glucose gel or little cartons of juice, or whatever they need to bring their blood sugar back up so they don't get those severe reactions.
What is the life expectancy for people with diabetes?
The life expectancy for people with diabetes used to be significantly reduced. And, in fact, life expectancy is reduced by a lot. If you get diabetes at the age of 18, I believe your life expectancy is reduced by 16 to 17 years. If you get it when your 40, it's reduced by about 14 years. That's a lot of years. On the other hand, if you get diabetes and you take care of it your life expectancy isn't reduced at all, neither with type one or type two. You have the same life expectancy. So my mission is to be sure everybody gets good care for their diabetes, and even though what I do for a living may not be all that dramatic, what I'm doing is giving people back years and I think that's wonderful, so this is a treatable disease and life expectancy can just be the same as everybody else, but people have to get treatment.
What are the most common causes of death for people with diabetes?
By far and away, the most common cause of death in people with diabetes is cardiovascular disease, heart attack and stroke. That's what people with diabetes die from. We end up seeing many of our patients with diabetes either diagnosed just at the time they had their bypass surgery or not that long after. So it is very important to work with people with diabetes to prevent their risk for heart attack and stroke equally as important, if not perhaps more so, to lowering their blood sugars.
Can I drink alcohol if I have diabetes?
Many people, when they get diabetes, are afraid that they can't drink alcohol anymore. Actually, that's not true. There are lots and lots of studies that show that moderate consumption of alcohol, both in people with and without diabetes, actually helps prolong life and lower the risk of cardiovascular disease. So it's good for you: it relaxes you, it may have antioxidant benefits, who knows? If you don't drink alcohol, I don't think it's a good habit to start. But if you do, you can do it safely. You do have to know a thing or two, however, because drinking alcohol lowers blood sugar levels. Most people don't understand this, and I've actually had some patients get into real trouble who go out after work, they're not used to drinking, they drink a couple of margaritas and their blood sugars go way too low. But it turns out that alcohol inhibits the liver's production of glucose. So when people with diabetes drink, they need to make sure they eat something, eat some carbohydrate to balance out the alcohol. They also may need to give less insulin or take less medicine. This is definitely something to discuss with one's health care provider.
How do wine and beer affect my blood sugar level?
Many people think wine has lots of carbohydrate in it, and it doesn't. It's got sugar alcohol, which doesn't raise blood sugar levels, so a glass of wine can lower your blood sugar levels. But beer, which is made from corn, has lots of carbohydrates in it, so increases blood sugar levels. And so, many times, switching from beer to wine, or from beer to low-carbohydrate beer, actually will lower blood sugar levels and help balance the diabetes. So alcohol, like anything, can actually be added into the diabetic lifestyle, but it needs to be done knowing the effects of the alcohol and how to prevent low blood sugar reactions.
How does smoking raise my risk of complications if I have diabetes?
Smoking is really, really bad for you if you have diabetes or even prediabetes because what it does is, it makes insulin resistance worse. It increases your bodies reaction it makes your body less reactive to insulin and it also causes constriction of things like the coronary artery, so it makes the risk for heart disease worse. It makes the blood surgers higher so in addition to the risk of cancer smoking actually markedly both worsens insulin resistance and coronary heart disease which is the primary reason people with diabetes die. Smoking is just not something to do if you have diabetes. It also can affect the blood flow to the feet and legs and diabetes can affect that as well and smoking makes that worse. It's just people don't usually realize the effect of smoking and diabetes but it's bad and people really should try whatever they can to stop smoking.
Should I see a general doctor or a specialist if I have diabetes?
Ninety-five percent of people with diabetes in the United States see a general doctor for treating their disease, and I think that it's going to stay that way because there aren't enough of us endocrinologists, and we're not exactly a field that's increasing. I think it's really important to find a good general doctor who will answer your questions and work with you. Unlike most diseases, diabetes is numeric, so you can keep track of your A1Cs, your blood pressure, your LDL cholesterol level. Take charge, bring your data to the doctor, really work with your physician to get yourself down to where you need to be, and make appointments that aren't urgent appointments. Don't just go because you're sick, go because you want to deal with the diabetes, and I think that most general doctors can manage diabetes just fine as long as you're proactive and put something of yourself into managing the disease. My caveat, though, is that if you have Type 1 diabetes or really-difficult-to-control Type 2 diabetes, that's when you may need to see a specialist. I see lots and lots of people with Type 1 diabetes because I think they need to see me - I'm adjusting their insulin, putting them on pumps, doing all sorts of things that I think requires a specialist for care. I think in that case you may want to go to a local center that's got some expertise in diabetes, but most people with Type 2 diabetes can be treated with their primary care provider.