Q: Hi Dr. G. I've been told I have, "Brittle Diabetes". That sounds scary and makes me feel bad... What does it actually mean?
A: I’m so glad you brought this term forward for us to discuss… I think the term “brittle diabetes” is itself an old and brittle description and should be discarded entirely. I agree that it has negative implications and I’m sorry you have been inadvertently disturbed by its use. Often doctors use terms to describe physiologic things without recognizing that patients can feel responsibility or even blame in a way, that is not intended.
“Brittle Diabetes”was actually used years ago (I hope not as much now) to describe a clinical picture of an individual whose diabetes was hard to control, a person who seemed to go from very high to very low blood sugars either rapidly or frequently, or inexplicably. Now remember, in bygone days we had relatively crude ways to measure glucose values that were inaccurate and often lagged behind true glucose values and we had insulins that did not match our bodies physiologic insulin in their onset of action, peak or duration. Also know that the longer an individual has DM the more they may have some impairment of counter regulatory hormones that prevent lows and patients may not sense the warning signs until sugars are dangerously low. Sometimes patients also have adrenal or liver or other organ disease than worsen glucose control. All these are real factors as well as a myriad of others especially the fact that some individuals with T1D still make a small amount of insulin whereas others make none and that makes it a tougher challenge to maintain normoglycemia.
Newer more accurate glucose monitoring systems have revolutionized our ability to recognize glycemic variability and create novel treatment and prevention strategies for both highs and lows. Better insulin delivery systems are available that are far more responsive as well as improved insulins and other meds.
At the Braden Diabetes Center we work with you and your physician to smooth out your control, improve your quality of life and problem solve so you can “travel through life well with diabetes.” Thanks for your great question! - Dr G.
Q: What is pre diabetes? What causes it? What are some ways (lifestyle, diet, exercise, etc.) to reverse it?
A: As many as 35 to 40% of residents in Marin County may have prediabetes and there are an estimated 86 million prediabetics in the US! (In addition to the 12.4% with Diabetes) Most people don’t even know that they have prediabetes, since most are asymptomatic for decades. Upon first diagnosis with diabetes large studies have shown about 50% already have some diabetic complications. Clearly we are making the diagnosis to late and missing opportunities to prevent this disease in millions of Americans. These staggering statics have initiated much more rigorous attempts to screen for diabetes sooner and we at the Braden Diabetes Center of Marin General Hospital are developed robust programs to identify prediabetes as early as possible and to offer a Diabetes Prevention Program (DPP) which will be approved by CMS and insurers.
Prediabetics are individuals who do not quite meet the criteria for a type 2 diabetes diagnosis – but have an abnormal glucose metabolism and body chemistries.
As opposed to type 1 diabetes – which is a totally separate condition accounting for only 5% of the total number of people with diabetes – type 2 diabetes is really associated with two main defects. The first is resistance to the action of a very important hormone called insulin and the second, which occurs throughout the spectrum of diabetes, is insulin deficiency.
When patients are resistance to insulin they are not able to utilize their energy properly i.e. not being able to use glucose, a primary building block of cells, efficiently. Instead of being used to build up the body – the glucose remains in one’s bloodstream – resulting in high blood sugar levels.
The root causes of prediabetes are in large part the primary conditions of western/modern living although now these lifestyles are worldwide including low daily exercise, weight gain, and diets skewed towards high-fat, high-salt foods, high refined carbohydrate foods and foods low in fiber and lean proteins. The DPP works with patients over time to change these lifestyles and early groups have shown great results with many patients becoming completely normal in their glucose regulation! A weight loss of just 5 to 7% has been shown to be effective in reversing prediabetes in more than 50% of individuals. Good food can be good medicine.
Stress may also aggravate insulin sensitivity so in terms of truly reversing the onset of diabetes we recommend stress management and work-life balance. Our bodies have a variety of metabolic responses to stress, allowing us to address true emergencies or tackle a pressing task. Metabolic responses to stress are rooted in the “fight or flight response” - our natural ability to protect ourselves in life-threatening situations. During a stressful situation - our adrenal glands have the capability to dramatically increase our steroid levels - allowing us to work harder, run faster, and exert ourselves in other ways. Due to an increasingly sedentary lifestyle and constant situational and psychosocial stress - the metabolic effects of our natural fight or flight response may do more harm than good:
In addition to metabolic responses - many individuals have compensatory behaviors in response to stress, including:
Alongside situational stress, our lives may be disrupted by a variety of psychosocial stress, including:
Best of health! - Dr G.
Q: What is your opinion of a sleeve gastrectomy as a cure for diabetes in patients who are > 100 lbs over their BMI?
A: Your question is a good one because I believe most medical doctors often overlook surgical options in the treatment of severe and persistent obesity complicated by Type 2 Diabetes or even prediabetes. There certainly are patients who become so obese that it is difficult for them to follow through or physically participate in exercise programs or dietary programs that will bring them to goal. Bariatric surgeries can result in prompt dramatic metabolic improvements with rapid drops in blood sugars and glycohemoglobin’s towards goal. Blood pressure and lipid levels are usually also markedly improved. Patients must be selected very carefully for the surgeries because they have both short and long term complications and consequences. Those of us who have practiced medicine for for many years have seen the many significant complications to long-term malabsorption of some nutrients. Additionally one should note that patient can regain weight even after bariatric surgery. That brings me to what we do at the Braden Diabetes Center which is working to help patients make gradual but permanent lifestyle changes to support optimal metabolic health over their lifetimes. This includes learning how to eat differently, cook differently, shop differently, exercise differently than most Americans who are caught in the diabesity epidemic.
It should be noted that there are also a number of medications that are now available that not only assist in the improvement in glycemic control but also assist in weight loss for type two diabetics. If oral and injectable therapies have been effective and patient remains significantly obese, bariatric surgery at an experienced center is certainly a worthwhile and beneficial option. Nevertheless patient still need to participate in active and ongoing diabetes education and self survival skills to “travel through life well with diabetes." - Dr G.
Q: I am taking long acting insulin(40 units) and short acting insulin(10 units per meal) and my primary care provider keeps increasing them but I am not seeing any improvement in my blood sugars. Why? I thought insulin is supposed to lower my blood sugars?
A: There are many reasons why a person might require higher insulin doses than usual. Insulin resistance refers to conditions that interfere with efficient insulin action. These can include higher body weights or obesity, inactivity, use of steroids and other medications, dietary choices, illness and infections and many others. So checking your blood sugars and letting your doctor adjust your doses to reach your glycemic goals is appropriate though may be frustrating. There are several medications that sometimes can be added to insulin in T2DM help improve insulin action. Ask your doctor or your diabetes educator and hang in there. Eventually you will see your blood sugars come into range. - Dr G.
Q: A recent up to date article indicated no pharmaceutical treatment necessary for type 2 diabetes if A1C is in low 7 range. What are your thoughts about this?
A: Your excellent question raises two important issues. One is what is the threshold for instituting medication is in T2DM? The answer is, it really depends on the patient entirely. The ADA and ACE recommend individual glycemic targets be set for each patient based on age, length of DM duration, presence of complications, comorbidities and other factors. This needs to be decided with one’s physician and DM education team. It’s a large part of what a good CDE can help you establish and it’s what we do at the BDC. An A1C as close to 6.5% is ideal IF THERE ARE NO CONTRAINDICATIONS. Secondly, we are now realizing that it’s not just A1C that we need to be concerned with but also “time in target” glucose range or “time in range.” We are getting a better look at this metric as we see more Continuous Glucose Monitoring tracings on our patients who may have both significant highs and lows and still have an A1C that looks pretty good. So we might choose to start meds or not depending on a further look at a Professional one week Continuous Glucose Monitoring tracing which we can arrange at the BDC and send to your physician. I think after education and maximal life style interventions are initiated A1C values in the low to mid 7 range would suggest treatment in order to prevent complications long term in the appropriate patient setting especially if CGM data suggests either high or low glucose excursions that are averaging out to an A1C in the 7 range. - Dr G.
Q: What can I do, I have horrible diabetic neuropathy. I am in constant pain and nothing works to ease my pain. It's out of control!
A: I’m so very sorry to hear! Diabetic peripheral neuropathy can be a very difficult complication to manage and can really impair quality of life. Chronic pain reduces motivation to comply with a person’s diabetic management such as exercise, can cause depression and insomnia and be associated with other foot problems. Pain often lessens with improved glucose control and making sure there are no other contributory factors such as nutritional deficiencies, vascular insufficiency, toxic effects of alcohol/lead or infection. Once optimal glucose management is initiated and other problems are screened for and treated, if severe pain persists there are a number of non narcotic pain medications that are very useful such as gabapentin and duloxetine and others. Further there are new implantable devices being tried for treatment of more severe intractable pain. We are in planning stages for a limb wellness clinic at the BDC to address diabetic neuropathy more comprehensively. Meanwhile ask your doctor about these measures and know that in my experience pain can be lessened. - Dr G.
Q: I am 69 years old and have been pre-diabetic for at least 10 years. Type-2 diabetes is very prevalent in my family (father and 3 siblings). I am taking medicine for high blood pressure which is well controlled. My cholesterol is a little high. Would it make sense for me to ask my provider about taking metformin at this point?
A: After ten years of Pre DM and with your other risks you are asking the right question! The answer depends largely on your level of blood sugar control. This can be estimated in part by checking your glycohemoglobin. Is it in the upper range of preDM, or the lower? Also the HA1c can be influenced by a number of factors which can change red blood cell turnover such as anemia and kidney impairment so it might be helpful to check a few weeks of your actual blood sugars and see how high your fasting, premeal and postmeal sugars are. Fasting glucose values under 110 and 2 hour postmeals under 140-160 probably don’t require medication now unless you are also having symptoms such as neuropathy. Intensive lifestyle changes in diet and exercises have been shown in large trials to work as well as metformin in preventing diabetes.
There are also special considerations. In women considering pregnancy metformin may improve outcomes, in some overweight patients metformin reduces insulin resistance and in women with PCOS there may be indications for earlier use. Specific recommendations are very individualized should be patient centric. Certainly it is also prudent to carefully monitor other CV risks such as blood pressure and lipid levels and treat those factors to recommended targets.
A very good next step is to discuss this more fully with your provider and keep abreast of the new more robust programs being offered and reimbursed for Diabetes prevention as of this year. - Dr G.
Q: Where can I get a list of foods suitable for a diabetes diet?
A: Building a healthy, balanced, and individual meal plan begins with a visit to our Braden Diabetes Center with a Registered Dietician/Diabetes Educator. The 2018 American Diabetes Association Guidelines no longer recommends any one specific “diet” for those living with diabetes. Instead, it is recommended to follow a healthy, nutritious, high fiber, portion control diet, rich in whole foods and whole grains. Really, this is the diet that all Americans should strive to follow for optimal heart and metabolic health, as well as cancer prevention. To start, we recommend using the Plate Method for building the optimum meal. If you picture a plate, half of it should be filled with non-starchy vegetables, such as a salad with oil and vinegar dressing or steamed broccoli. One quarter of the plate should consist of your carbohydrates, like whole grains or starchy vegetables. The last quarter of your plate is dedicated to lean protein, such as 3 oz of baked chicken or fish. Those living with diabetes should consider making heart healthy diet choices as well. Heart disease is more prevalent in those with diabetes, so moderating fats and high cholesterol foods are especially beneficial. On our website under Patient Resources, we have a variety of handouts available to reference creating a healthy plate, food choices, and serving sizes. At the Braden Diabetes Center, we have knowledgeable Diabetes Educators and Registered Dieticians who can go through the specifics of your diet and lifestyle and find which foods work best for you! - Dr G.
Q: Is a gluten free diet recommended if you have diabetes?
A: Gluten free diets seem to be popular these days and advertised as a “healthy” diet. If you are living with celiac disease, then it is best to follow a gluten free diet. Gluten is a protein found in wheat, rye, and barley. Celiac disease is a digestive disorder where the body has an immune response when gluten is eaten. This immune response causes inflammation and damage to the lining of the small intestine. About 1% of the population is affected by celiac disease and it is more common in those living with type 1 diabetes. In fact, it is estimated that approximately 10% of those with type 1 diabetes also have celiac disease. So if you have type 1 diabetes, you may be more likely to have celiac disease as well. It should be noted that gluten free is not necessarily healthier if you don't have true celiac disease or gluten sensitivity. In order to replace the gluten in many of our favorite foods, substitutes such as corn and potato starch are used along with many preservatives and sweeteners. It is always important to read your food labels carefully, even on items that are labeled as “health foods”. As always, listen to your body. If you don’t feel well after consuming gluten, then adjust accordingly. If it doesn’t cause any issues, then carry on! Keep in mind it is best to choose whole wheat options when consuming gluten. Whole wheat is higher in fiber and won’t cause your blood sugar to spike as it would with refined carbohydrates, such as white bread or pasta. - Dr G.
Q: I’ve been using an insulin pump for years, and I was wondering if there are any recent updates in pump technology?
A: As a matter of fact, this is a very exciting time for technology in the diabetes world! The first semi closed loop hybrid system has been approved. What this means is there is now an insulin pump, the MiniMed 670G, which communicates with a continuous glucose monitor (CGM) in order to auto regulate your insulin delivery. The CGM is able to talk to the pump, and auto adjust the basal rate insulin delivery based on your blood sugar readings. Much as there are now self-driving cars, there are also advances in the technology used with pumps to make them work more automatically. Pumps are becoming smarter and smarter, making living with diabetes less of a burden and decreasing complications. Stay tuned for more updates, and as always our knowledgeable staff at the Braden Diabetes Center is available for your diabetes needs! - Dr G.
Q: I’ve had type 1 diabetes for about 10 years. I take insulin injections but am getting sick of it so I’m considering getting a pump. Are there any major pros and cons to a pump?
A: Insulin pumps have numerous advantages. They offer precise dosing and setting options which give you more control over your diabetes management. You won’t have to take multiple injections every day or need to carry those supplies with you when you’re on the go. An insulin pump is also a discrete way to deliver your insulin. The major disadvantages are the occasional error with the device, and the fact that you will now have something on your body around the clock. Deciding if a pump is right for you may depend on your lifestyle and personal diabetes goals. Talk to one of our diabetes educators to learn more about pumps and find which one may be right for you! - Dr G.
Q: I was recently diagnosed with type 1 diabetes. I’ve always lived a healthy life and was shocked to hear that I now have diabetes. Can this happen to anyone?
A: A new diagnosis can be full of emotions, especially when it is unexpected. Type 1 diabetes is in fact a disease that can affect anyone, no matter how healthy or unhealthy you are. This leaves you to ask, “Why me”? Although the cause is still under debate, there are some factors that may contribute to diabetes. This can include genetic, lifestyle, and environment components. Type 1 diabetes is an autoimmune disease, meaning the body “attacks” its own healthy cells thinking they are foreign. In type 1 diabetes, the body attacks the beta cells located in the pancreas. These cells are responsible for producing insulin, hence why those with type 1 diabetes must take insulin in order to regulate their blood sugar levels. For now there is no clear answer as to why people get type 1 diabetes, but with more research and advances in technology hopefully there will be one day! - Dr G.
Q: I love pasta but my blood sugar is harder to maintain when I eat it. Is this a food I should cut out of my diet since I have diabetes?
A: Pasta is a food that is higher on the glycemic index, meaning it will raise your blood sugar more than foods lower on the glycemic index. Pasta does not have to be avoided completely if you have diabetes though! Try a whole wheat pasta. This will be higher in fiber and lower on the glycemic index, so it will help you avoid that big blood sugar spike after your meal. Also, portion control is key. It is easy to sit down to a big, yummy bowl of pasta for a meal. Next time you want this tasty food, have a small serving and pair it with 2oz of lean protein like chicken or fish, and some non-starchy vegetables like steamed broccoli or a simple oil and vinegar salad. When planning meals, don’t feel like you have to deprive yourself of certain foods. If you love pasta, you can still eat it! Just be sure to keep your meals balanced and adjust accordingly. - Dr G.
Q: Can someone with diabetes get a transplant of their pancreas?
A: There are many factors at play here, there is no simple answer. Fortunately, pancreatic transplants are certainly being done at major medical centers in this country and around the world. If you are a candidate your doctor will discuss with you how to get on a transplant waiting list. - Dr G.
Q: Once I start diabetes medications, will I have to take them for the rest of my life?
A: No wise person would ever predict what will happen for the “rest of your life,” there’s just so much change possible and it sort of makes your meds feel like your meds are a “life sentence,” a punishment, or a failure, rather than a helping hand to a healthier YOU! As I write this I am thinking, “well, what about Type 1 patients?” Even within the lifetime of children with Type 1, there may well be a cure for this disease. Many researchers work every day of their lives to see that happen! With Type 2 Diabetes management, fluctuation in medication can certainly take place. Sometimes I have seen so much improvement in lifestyle with weight loss and exercise and dietary change and stress management that patients can go off orals agents and even insulin! Other times meds are continued but in more effective combinations, at lower doses. There are many interacting factors and meds are really important but just one of them. What we really focus on and your doctors will as well is to get your diabetes well controlled to reduce complications. It’s easy to feel like a failure when you are asked to begin a medication but sometimes it is the best way to deal with a particular phase of your diabetes and stay well! - Dr G.
Q: What time of the day is best to exercise?
A: I think you’ll find your best exercise takes place when you can manage to monitor your blood sugars before and after if you are on insulin or medications. If not, then any time of day works but again exercise can actually bring the glucose values down, or if really vigorous and when insulin levels are too low, it can result in stress “highs.” Getting to know your individual response to exercise will allow you to put it in a time of day that works best with your schedule, meals and meds so it can be safe, effective for conditioning and fun! - Dr G.
Q: What kind of exercise is best for diabetes?
A: The answer is, any and all kinds!!! We are mammals and we are meant to move! Exercise helps bring glucose into the muscle, makes our metabolism more efficient, reduces our insulin production requirement, helps optimize weight, conditions the heart and gladdens the spirit. Can you tell I’m enthusiastic? The best exercise is the one that YOU enjoy and can perform safely. Exercise can often vary to prevent joint injury. There are special cases like patients who have neuropathy, visual disturbances, foot ulcers, active heart disease, etc., for which very SPECIFIC exercise regimens must be designed. For the vast majority of healthy people with diabetes they can do whatever they want right up to participating in the Olympics! The recent ADA recommendations are for at least 150 minutes of aerobic exercise per week. Talk to your doctors and diabetic educators about what YOU want to accomplish and what you would enjoy. It only takes me a stroll through the hospital wards to remember how lucky one is to be able to be up and active - don’t waste a day! We offer an exercise classes with blood sugar checks. Give us a call if you would like more information. - Dr G.
Q: I love wine! Do I have to give it up now that I have diabetes?
A: Wine and other alcoholic beverages can certainly be included in the healthy diabetic meal plan and may even enhance cholesterol panels in some people but there are a few caveats! Wine is pretty high in calories so take that into account if you’re watching your weight. Also alcohol can cause low blood sugars in some circumstances and high sugars in others. Make sure you know how wine affects your medications and or insulin. Our diabetic educators can help you to include wine in moderation in your diet safely so it’s a great question to bring to class for more specific recommendations! - Dr G.
Q: My doctor says I have high cholesterol levels. I’m already cutting down on carbs. Do I have to cut down on fats and cholesterol too? What can I eat?
A: It does seem like every time we read an article we are told to STOP eating SOMETHING? But actually the most recent ADA dietary guidelines stress that there is no one dietary recommendation for Diabetics. The goals are good glucose control, heart healthy cholesterol levels and safe blood pressures and staying fit. Folks with diabetes have higher risks for heart disease so this is especially important. Forget “diets” and ask your CDE/RD to help you create an individualized nutritional plan for YOU based on your food preferences, eating habits, work schedule, cooking and eating out history and food availability. Choosing whole unprocessed foods including the healthy complex carbs, lean proteins and healthy fats which are unsaturated fats and low cholesterol but highly nutritious and delicious can fill your basket at the farmers market with an amazing variety! These foods are satisfying, full of flavor and will lead to improved weight control over time with some coaching from Katy or Veronica or other members of our team. I’ve been known to give a recipe or two myself (all the time)! It’s not what we cut out, it’s what we include! Find a world of foods you can LIVE WITH and enjoy! - Dr G.
Q: Not sure my Doctor is managing my diabetes care. My A1c levels are up to 7.3 from 7.1. My Doctor tells me to exercise more & watch my carb intake, but I am concerned. Shouldn’t I be on medications? Or have things changed in the treatment for diabetes care?
A: Great question! Your Dr. is right to start with lifestyle modifications including Medical Nutritional Therapy and exercise delivered by a proactive care team that focuses on “patient-centered care”. This means that the goals of therapy and recommendations must take into account patient preferences, needs, and values. These measures can result in reversal of hyperglycemia in many patients and are the initial cornerstone of treatment depending on the A1C at the time of diagnoses. BUT, you are right to be concerned about a rising A1C over 7% because, depending on the individual, life style changes are not always sufficient to treat hyperglycemia and get blood sugars to goal. Current recommendations are to reassess an individual’s progress in one to three months and if glycemic targets are not met to add pharmacologic therapy to lifestyle. Subsequently it is recommended to be monitored every 3 to 6 months until goals are met for further adjustments in medications and lifestyle as well as monitoring of the other associated goals for blood pressure and lipid control. Diabetes Education Centers such as as ours can help you understand your goals and how to get there and your Dr will probably be glad to know you want to be proactive in treating this condition optimally to avoid complications! - Dr G.
Q: Can I still travel if I have diabetes?
A: Yes -- you can absolutely travel if you are living with diabetes. This disease does not have to limit the activities in your life, but there are a few steps you can take to better prepare for your travels. Always plan ahead by having extra supplies on hand, including test strips, insulin, syringes, pen or pump supplies, oral medications, and batteries. It is important to have fast acting glucose on you at all times to treat hypoglycemia and extra snacks in case you are in a situation where a meal is delayed. Always keep your diabetes supplies in your carry-on bag. You never know when your checked bag can get lost, so it is best to keep these valuables on you at all times. Happy travels! - Dr G.
Q: How can I feel more comfortable giving myself injections in social situations?
A: Giving yourself injections in front of others can feel uncomfortable at times, but having diabetes is not something to be embarrassed about. It often helps if you tell the people around you what you are doing and explain to them why you need to take injections. Many people have a basic understanding of diabetes and often may know someone else who also has diabetes. Use this as an opportunity to educate others; it might even bring you closer to one another. - Dr G.
Q: How do I avoid days when I can’t seem to keep my blood sugar stable?
A: Having diabetes is a 24/7 job. There are going to be good days and bad days. It is important to try your best and not be too hard on yourself if you don’t get the results you were hoping for. Work on correcting it, and know that tomorrow brings a new day to reach your goals. It helps if you have a routine and stick to it as best as possible. Plan ahead for the days you expect to deviate from your routine. Also, don’t forget to take time for yourself. A daily walk or meditation can help relieve stress and keep your mind clear and focused. - Dr G.