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How is type 1 diabetes treated and controlled?

Diabetes Treatment

Anne Peters, MD, FACP, CDE (Professor and Director of Clinical Diabetes Programs, USC Keck School of Medicine) gives expert video advice on: What happens to my body if my diabetes is not treated?; Why do I have to care for my diabetes every day?; Can diabetes be cured? and more...

How is type 1 diabetes treated and controlled?

Type 1 diabetes means that an individual doesn't make any of their own insulin so that means that they need to give insulin shots to restore insulin to their body. This is actually harder than it sounds because in all of us, our body makes a little bit of insulin all day long and that little bit of insulin is called the basil insulin and what that does is inhibit the liver from making too much sugar. Because all of is need to have blood sugar so when you go to sleep overnight, you don't wake up in the morning with a blood sugar of zero. You wake up in the morning with a blood sugar of a hundred. The reason for that is because your liver is making sugar. Every time that you eat, your body makes insulin and responds to the food that you're eating. It makes more insulin if you are eating more carbohydrate or starch. It makes less insulin if you are eating less. So what we have to do is help people with Type 1 diabetes both give basil insulin, or 24 hour insulin. We also have to help them give insulin before each meal to match exactly what they are eating. If you get it wrong and give too much insulin with Type 1 diabetes, your sugars can go way too low which can be dangerous and if you don't give enough, sugars go to high which may not be dangerous in the short term, but in the long term can cause the complications of diabetes.

How is type 2 diabetes treated and controlled?

Type 2 diabetes is always two things: It is always insulin resistance which means that the body doesn't use the insulin it makes normally and it is also always insulin deficiency. It is different than with type 1 but it is a process where the body makes some, but not enough insulin. With type 2, the first way you want to do is help reduce the resistance to insulin. You can do that by losing weight and by exercising. Those are good ways to reduce insulin resistance and part always in the treatment in type 2 diabetes. The first pill that we recommend that you use is a pill called Metformin which is a very good pill for helping the body to use insulin better. Then there is a number of other pills that can be added to that as diabetes is treated. Pretty much everyday it seems like we are having new pills for treating diabetes. If that doesn't work, there is injectable drugs. There is an injectable drug that is called Exenitide, which helps people with weight loss and blood sugar control and it isn't insulin. If the pills and the drug like Exenitide doesn't work, then people go on to be on insulin as well as type 1 diabetes and often they are on a combination of insulin and pills because Type 2 was always those two things. People always make a little bit of their own insulin and they are always somewhat resistant to whatever it is you do.

What happens to my body if my diabetes is not treated?

If your diabetes is not treated, there is damage to all sorts of organs. To your eyes, you can go blind. To your kidneys, which can fail. To your nerves which stop working. And it's nerves to all sorts of your body. Nerves to your heart, nerves to your feet, nerves to your bladder. It increases your risk for heart disease. It's pretty bad if you don't treat it. I wouldn't recommend it. I think it's very important to lower blood sugars to try to prevent those complications.

Why do I have to care for my diabetes every day?

I think diabetes is one of the hardest diseases to treat of any because it doesn't ever go away. It is everyday. It is day in, day out. It is every meal you eat. It is really related to so much of what we do for fun. People eat for fun. We go out with friends. We eat because we are bored. Food and our lives are so integral and diabetes means you don't process food normally, and so you have to think every time you eat about food and you really can't ignore it. You may be able to take an afternoon off but it's a disease that has to be in your mind just as much as breathing or brushing your teeth or anything that is very fundamental, because otherwise it gets the best of you; your sugar levels go too high and then you get complications.

How does my general health affect my diabetes treatment?

Diabetes has a big affect on your general health, but oddly, I think that many people with diabetes have general health that is better than those who don't. I just saw a really sweet 12-year-old boy who has Type 1 diabetes, and his mother was asking me questions; the mother asked me about curing diabetes. This boy was not exactly heavy, but you could tell he could get on the heavy side. His mum wanted to know about curing diabetes, and I looked at the kid and I said, "You know, someday in our lifetime, I think we're going to cure Type 1 diabetes," and he looked at me, and he said, "No, I don't need that." I said, "Why?" and he said "Well, I've had diabetes since I was seven, and I'm pretty good at it. If I didn't have diabetes, I think I would just eat too much, and I'd get really fat. Because I have diabetes, I'm really, you know, aware of what I eat and my exercise," and he said, "I think it's keeping me healthy, so I don't mind having it." I thought; that's the most incredible attitude I've ever seen, but it's true! Many, many, many of my patients I think take better care of themselves, because they have to be so aware of their bodies, their medications, and everything else. So, that's the upside to diabetes; it makes you health aware and it makes you involved in preventing disease.

Can diabetes be cured?

Type 1 diabetes can be treated, but not cured; not yet. Type 2 diabetes, in a way, can't be cured; it can certainly be treated and it can even be prevented. However, anybody who's at risk for type 2 diabetes, even if it nearly entirely goes away, is still at risk for getting it back as they get older. So, I never tell people they're completely cured. They still have a risk. However, I do think that in the future, particularly with type 1 diabetes, we'll figure out a way to cure it. It's just that we don't how long it will be until we cure anything; it just someday will happen.

What is "insulin" and what does it do?

Insulin is a molecule that is made in the pancreas, in your islet cells. It's present in all sorts of species, pretty much all of us and it comes out when you eat carbohydrate. It's a really neat hormone as it lowers your blood sugar levels by pushing sugar into your cells and then it goes away when you don't need it, so you don't push too much sugar in your cells. So it's a response to food and it's in a really fine balance between too much and too little and there are other hormones that act to sort of stabilize it, like glucagon or the stress hormones like adrenaline. All of those hormones interact together to keep blood sugar levels exactly where we need them to be, day in, day out, as we live our lives and we need blood sugar to fuel our muscles and our brain and keep us going.

What does it mean to have insulin resistance?

Nearly everybody with Type 2 diabetes and pre-diabetes has what we call insulin resistance. Insulin resistance means that the cells don't respond to insulin normally, so it's as though normally, when you open a door to put glucose into the cells, you have to push it very lightly. When you have insulin resistance, you have to push really hard. That means you have to use lots of insulin molecules to open up the cells for glucose to go inside, and what we think that that does over time is that it may burn out the pancreas. It may make the body unable to make quite enough insulin to help the glucose go into the cells. So, insulin resistance is a resistance to the effectiveness of insulin to get glucose into the cells. Everybody who has diabetes knows that, for instance, if they have a high blood sugar and they go jogging around the block, that in general, their blood sugar will fall because exercise lowers insulin resistance and now their sugar can go into their cells and everything is just right. So it's an interesting problem, insulin resistance. In people with type 2 diabetes, at least, the high blood sugar levels need to be treated.

What are the tips for performing a daily insulin injection on myself?

What's really good is that the new technology, the new needles and things, are so small and so easy that they hurt much, much less than they used to. But it's important, actually, to find out what size needle is best for you, because there's mini needles, and short needles, and irregular needles, and there are different gauges. So if you get the smallest, finest needle that's right for you, it will hurt the least. So, I actually suggest that people look to find out what kind of needles are available in their area, and then find out which ones they can use that are going to be the least painful.The other thing is that people need to rotate their injections around instead of giving it all in the same spot. That area eventually sort of becomes abnormal. You want to rotate around and give the shots in a variety of places.And finally, there are people who use insulin pumps. Insulin pumps are a way of giving insulin through a pump under the skin, where you insert the pump needle once every three days and then you don't have to give all those shots. So insulin pumps are an alternative to insulin injections, and that's something that people might want to ask their health care provider about.

Why can't I take insulin by mouth?

The reason you can't swallow insulin and have it work is because there are enzymes and acid in your stomach that just break it down. So it doesn't get into your circulation and it won't work. It's a fragile peptide hormone that comes out inside your bloodstream and isn't meant to be swallowed. Now, they're working on different ways of giving insulin. There's inhaled insulin which is actually on the market in the United States which allows you to take puffs of insulin into your lungs. The problem with that is that it's still insulin so I have patients who think inhaled insulin is gonna be easy but in essense you still have to check your blood sugar and adjust the balance between food and insulin. And my biggest concern about it is that, although it does work to lower blood sugar levels, we don't know what the long term risk to inhaling all that insulin into your lungs is. So they're doing follow up studies now to see people over time to make sure that's safe. But if I have somebody who absolutely won't give a shot, they may take inhaled insulin and it can work for them. Now the caveat is is that many of the people with inhaled insulin have to give one shot a day so it may not be shot free. There's other ways that they're looking at giving insulin which involve spraying things into the back of your mouth or putting it on the inside of your gums but all of these ways are difficult because you really need to make sure that people get the same amount each time you give the dose because if you don't, their blood sugars can go too high or too low. So the delivery of insulin, other than through injections or through a pump has been really difficult to figure out.

Why is it important that I learn to give myself insulin injections?

I think that everybody with diabetes really needs to take care of their disease themselves. I also think that it's a family disease; I think that everybody who's involved in the life of someone with diabetes needs to be there for support and love, but they can't do it for them. Nor, mind you, can they be the diabetes police. I see way too many husbands and wives where it becomes a big deal about who eats what and when, and I want people with diabetes to be just the same as anybody else, but they do have to be more mindful of certain things in their lives. But being autonomous is important. Now I do have family members who help the person they love give a shot sometimes just to make it easier. Sometimes you just don't want to do it. But by and large, giving shots is easy, giving shots is pretty painless, and it really needs to be up to the individual to do it unless there's an extreme circumstance where they're blind or they can't otherwise give it.

How often and when are insulin injections given if I have diabetes?

In my patients with diabetes, especially Type-1 diabetes, they give insulin injections generally between four and eight times a day. And the reason for that is because they need to give insulin every time they eat. And most of us eat three meals a day, so people give short-acting insulin before each meal, and then they give long-acting insulin, or basal insulin, once a day. Sometimes they give even more injections than that, and sometimes if they're Type-2 diabetic patients and make their own insulin, they may only need to give one or two shots. Now, I happen to be a specialist in diabetes, so I use insulin in a way that tries to mimic normal. A lot or people with Type-1 diabetes have just done two shots a day, and in general, I don't think they get their diabetes under control that's as good, just because you really need to take shots when you eat or at least give insulin through a pump when you eat.

Should I eat after I take insulin if I have diabetes?

When people give insulin they need to understand their insulin because there are many different types of insulin and some insulins start working really fast and some insulins start working more slowly. So, say it's before a meal and someone's blood sugar is too low, say 60 and 100 is normal, and they give an insulin shot in anticipation of the meal. That could make their blood sugar go down too low too fast. In that case, someone might need to eat first and then give the shot later. There may be people where their blood sugar is way too high, so they want to give a shot, wait for 30 to 60 minutes and then eat after the shot has helped work to bring their blood sugar down. So, the timing of insulin relative to the meal is something that each person needs to work out, and work out with their health care provider, because it may differ. I have patients who for whatever reason, maybe they're elderly or sick, are not going to know how much they eat in advance, so they'll eat and then give the insulin because that's the only way they'll know how much they're going to eat. So, this is a balance for each person that really needs to be worked out.

How long will it take me to learn how to regulate my blood sugar level?

When people first get diabetes there is a tremendous amount to learn, and so my first advice is not to try to learn it all at once. But rather what I try to teach is survival skills, meaning how to get through the first day or two. Almost everybody is completely overwhelmed. But I think the things that help people learn are, for instance, taking notes or bringing a tape recorder, or bringing a list of questions - really starting to work to get some of the answers that make it make sense. Then I know that within a month nearly everybody settles down and they have got it figured out and they are really doing beautifully. Some people have more problems than others. Some people's bodies are tougher than others. Some people are sicker than others. There is a huge amount of variability. It is really a step by step process. It's like school for the first month. You really have to learn a whole lot that you didn't know before. If people make that commitment, by the end of the month, they really know a lot. They are incredible. They are really able to take care of their disease. So it really takes a lot of effort but it is completely doable.

Why do I have to keep records of my insulin dosage and blood sugar levels?

When people come to me with their diabetes it's very hard for me to know how to fix it unless I know what's been happening, and the way I learn from my patients what's been happening is for them to provide me with information to show me how much insulin they gave, how much they ate, whether they exercised, if they were sick. There's all sorts of variables that can affect blood sugar levels that help me adjust insulin in any given patient. And what I tell patients to do, patients hate to keep records day in, day out. I mean I can't imagine having to write down what I eat every day, but I think that I could do it for three or four days, so what I tell people to do is just before your going to go see your health care provider take a couple of days and just write down what you're doing and how your blood sugars are and everything else, and they can look at them and they can say, "Gee, your breakfast dose of insulin is fine, but your lunchtime is too much", and then you can get really helpful adjustments in your insulin, and that makes it a very useful interaction.

What side effects should I expect from my diabetes treatment?

Basically, all the medications for treating diabetes can have side effects. Many of them, however, are related to the dose of the medication and to the timing of the pills and taking the pills with meals. So, there is sort of an art to giving drugs in a way that works. The other thing is, many times patients teach me about side effects because I might not have known that whatever they are feeling is a side effect. I think that people need to really watch their bodies and when they start a new medicine that they make sure that you tell your doctor if you think that something is not right. I also think that it is a really good idea to not start a whole bunch of pills at the same time because then you don't know which one is making you sick. So, what I say is ask your doctor if you can start them sequentially: start one and then two weeks later start another and see it is feeling and how you feel with it. I also suggest, asking your physician the most common side effects of the medications they are giving you.

How soon will I start to feel better after taking my diabetes medication?

When people are first treated for diabetes and have really high blood sugar levels; say someone comes to see me and their blood sugar level is 400 and normal is 100 and I get their blood sugar levels down to normal, within a week or two they are going to feel a lot better. They are not going to be urinating so much. They won't be so thirsty. They may, by the way have visual problems though, because if you start with a really high blood sugar and you drop it suddenly, the lens in the eye actually becomes somewhat distorted. It doesn't react normally, and some people in the first month of diabetes treatment may notice very significant changes in their eyes and that will go away as they get accommodated to having normal blood sugar levels. The problem is that most people with diabetes have no symptoms of diabetes. So often people who come to see me who have been diagnosed with diabetes and they don't worse. Suddenly they are taking drugs and they may not like to take drugs and they get a side effect from the drug and all this other stuff happens. So, you may not feel better at all. You have to feel better in your head that you are going to be healthier, but often times it is not an actual feeling of wellbeing physically. It is just the knowledge of being feel sick so my treating them doesn't make them feel better, and in fact it may make them feel healthier.