Summary for HealthiNation’s Health Insights: Diabetes

The following is an interview with Dr. Derek LeRoith, Chief of Endocrinology, Diabetes and Bone Disease Department at the Mount Sinai School of Medicine

Hosted by Dr. Holly Atkinson

Insights: Diabetes and Blood Sugar

DR. HOLLY ATKINSON
Welcome to HealthiNation. I’m Dr. Holly Atkinson. If you’re a diabetic, you’re probably aware that the question of how tightly to control blood sugar is a controversial topic. I sat down with Dr. Derek LeRoith, Chief of the Endocrinology, Diabetes and Bone Disease Department at the Mount Sinai School of Medicine, to talk about the controversy and what’s best for Type 1 and 2 diabetics.

DR. DEREK LEROITH
There’s a lot of discussion in the press about these issues but what’s not spelled out to the patients is, if you take the type 1 diabetic, blood sugar control is critical. It’s been shown in some of the best trials that tight control prevents or delays the progression of eye disease and kidney disease and, in fact, years later, after the trials have finished, those type 1 diabetics who were well controlled had less cardiovascular disease 10 to 15 years later. So it’s unquestionable – in type 1 diabetes it’s critical. In the type 2 diabetics, the controversy has been about tight glucose control and cardiovascular outcomes. What was forgotten there is that retinopathy and other aspects of the microvascular disease – the small vessel disease – was prevented. So, tight glucose control is important for both type 1 and type 2. Regarding the cardiovascular outcomes in type 2 patients, the interpretation of most physicians and investigators in the field of diabetes is that early in type 2 diabetes, tight control will give you a positive outcome. But late in the disease, after many years of already having diabetes, you’re surely going to have some underlying cardiovascular disease. Or if you already have evidence of cardiovascular disease, then one should be much more careful at how rapidly you bring the blood sugar under control. And that led to some of the complications in those trials because much older patients with established cardiovascular disease were used.

We measure tight glucose control by measuring the A1C because this is a measure that is done every three or four months, three or four times a year, and this gives us an idea of the level of the blood sugar over the previous three months. The American Diabetes Association suggests that you try to reach a level of seven or slightly less than seven [percent]. The American [Association of] Clinical Endocrinologists believes you should get down to 6.5. But if we could get more patients down to seven, or even just below seven, we would have a much better outcome in terms of the general population of diabetics. It used to be a mean of say nine, now we have the average patient down [to] eight or slightly less. But we still will find that about 50 percent of our patients have not reached the goal, which is seven percent A1C.

DR. HOLLY ATKINSON
Why is that?

DR. DEREK LEROITH
Because there are so many variables: When you’re overweight, you’re insensitive to many of the medications, like insulin. Taking the medications, some good medications maybe expensive because they are new on the market. The difficulty with losing weight with diet control and…sometimes it’s just that the body doesn’t respond as well as you’d like it to. Especially when you’re aging, it becomes more resistant to many of these effects.

DR. HOLLY ATKINSON
So here’s the insight. Tight blood sugar control for type 1 diabetics is critical. For type 2 diabetics who are newly diagnosed, tight control is also critical. But if you’ve had type 2 diabetes for a while, you’ll need to be careful about how quickly you bring your levels under control. Be sure to work closely with your doctor on the right strategy for you.

Insights: Diabetes and Diet

DR. HOLLY ATKINSON
Welcome to HealthiNation. I’m Dr. Holly Atkinson. As a diabetic person, you know it can be difficult to make the right food choices. But there is help out there. I spoke with Dr. Derek LeRoith, Chief of the Endocrinology, Diabetes and Bone Disease Department at the Mount Sinai School of Medicine, about the importance of working with a nutritionist.

DR. DEREK LEROITH
What’s very important is for the nutritionist to work with each individual patient. So, what they do is they ask the patient, “what are your favorite foods, what do you generally eat?” and they learn about the patient’s ability, whether it’s socioeconomic or ethnic, and then they vary the diets for weight loss according to what’s available to the patient. They also then help the patient understand what’s important in terms of what happens to the glucose after you’ve eaten because a lot of the post-meal rise in sugar causes a lot of the complications. So they can work with the patient and design diets that would be appropriate for that individual patient, both for weight loss, but also for controlling their sugar. The consensus is that a Mediterranean-type diet, with lots of fresh fruit and vegetables, is the best way to go. And again, the nutritionist would help them work with how much of the fresh fruit and vegetables to include in the diet, the cereals, and what type of meats, fish and carbohydrates they should be eating. But the more fresh fruit and vegetables, the healthier the diet is going to be.

DR. HOLLY ATKINSON
What about the no-no’s? What are the bad foods?

DR. DEREK LEROITH
I think it’s all a question of quantity. So, if a patient could not live without ice cream, one would say, “well, try and reduce the times that you eat ice cream to perhaps once a week, twice a week, just to reward yourself.” So there are no “no-no’s,” but quantity is what’s very important. Cutting down on the high fat diets, the simple sugar diets, try to increase the complex carbohydrates, all of those are relevant in everyone’s diet … and a mixture of some fats, carbohydrates and protein, which the nutritionist will help them with.

DR. HOLLY ATKINSON
Just quickly give me some examples of complex carbohydrates.

DR. DEREK LEROITH
So, rice, starch…like bread, those are complex carbohydrate—requiring some breakdown of the complex carbohydrate to a simple sugar, as opposed to when you have sugar in various sodas, for example. So the real “no-no” perhaps is a soda, which has 180 calories in general…the sugar goes right into the body. That’s a simple sugar. Two slices of bread is about the same as a soda, but bread is a complex carbohydrate.

What’s very important is to try and lose weight because five pounds, ten pounds weight loss will reduce a diabetic’s blood sugar – much easier to control the blood sugar, much more sensitive to the medications. It will drop their blood pressure and make them require less anti-hypertensive (blood pressure) medication, and it will drop their cholesterol as well. Just a few pounds is enough in terms of weight loss to actually improve many of those factors that cause the long-term complications.

DR. HOLLY ATKINSON
Is there a consensus in the medical community about the most effective way that diabetics can go about losing weight?

DR. DEREK LEROITH
The general consensus is that if you reduce your caloric intake, you will lose weight. If you reduce your caloric intake and exercise, you will lose weight and you can maintain the weight loss by exercising. The problem is that there are so many different diets that are available. Most of the fad diets help you lose weight immediately, but they don’t help you keep the weight off. What’s important is sustaining it and that takes a lot.

DR. HOLLY ATKINSON
So, here’s the insight. Nutritionists are a great resource in helping you learn about how food affects your blood sugar levels. They’ll help you personalize your diet, making sure that you’re getting lots of fresh fruits and vegetables and eating the right amount of fat, protein and complex carbohydrate. If you must have some of your favorite treats, remember, everything in moderation. And losing just a little weight can really help you control your diabetes.

Insights: Diabetes and Exercise

DR. HOLLY ATKINSON
Welcome to HealthiNation. I’m Dr. Holly Atkinson. You have diabetes, so you eat well, right? But are you exercising? Dr. Derek LeRoith, Chief of the Endocrinology, Diabetes and Bone Disease Department at the Mount Sinai School of Medicine, says you should be. I asked him, what exercise is best for people with diabetes?

DR. DEREK LEROITH
Physical exercise by itself, even in the absence of weight loss, is actually equally good. If you exercise, you’re able to put sugar—glucose—into your muscle much more easily. That makes your muscle more sensitive to insulin, which is one of the problems that the type 2 diabetic has. So the blood glucose will come down from exercise, their blood pressure will come down, their lipids will come down, their cardiovascular system will improve and so it can delay many of those complications.

DR. HOLLY ATKINSON
Are there any forms of exercise that we are know are better than any others in helping diabetics control their blood sugar?

DR. DEREK LEROITH
There are many studies that suggest one form or the other – aerobic exercises versus muscle strengthening exercise—[is better]. And actually, each of them has shown to give you positive outcomes. Any exercise for about 20 to 30 minutes, five or six days a week is going to make a big improvement in the diabetic’s control of their sugar, blood pressure and their lipids. You often see people walking, particularly in the bad weather, they’ll walk in the malls to try and get their 30 minutes of exercise.

DR. HOLLY ATKINSON
What combination is the ideal for helping control blood sugar? Is there one?

DR. DEREK LEROITH
Well, I think aerobic exercise, if for example, on a treadmill – if you can go on a treadmill for 30 minutes and actually run and get your heart rate up, but again diabetics have to be careful because they need their physician to first determine if they have any cardiovascular disease, you don’t want to suddenly precipitate any side effect from the exercise. Aerobic exercise for 30 minutes probably is the best. Even though strengthening the muscle also improves the blood glucose reduction, I think the aerobic exercise is probably the best way to go.

DR. HOLLY ATKINSON
But if you can put the two together, is that even better?

DR. DEREK LEROITH
Even better. I think the right combination is first to go on a diet to lose weight and then to start exercising to maintain the weight reduction. And some very good studies have shown that individuals who lose weight by dieting and have the tendency to put back the weight, when you then exercise, you overcome that effect.

DR. HOLLY ATKINSON
We got some questions from people with diabetes. This is from Hallie:

“My mother developed diabetes later in life. Am I likely to do the same and what might I do to prevent it?”

DR. DEREK LEROITH
Let’s assume the majority of late-onset diabetes is type 2. It runs in family, it’s genetic and what that means is that any of the individuals in the family have a possibility of developing diabetes. The major thing to prevent diabetes from developing in a predisposed individual, like the daughter, is weight control. If she can continue to keep her weight down and to exercise, there’s a very good chance that she will delay any chance of developing diabetes.

DR. HOLLY ATKINSON
So, here’s the insight. Exercise is good for diabetics, even if you aren’t trying to lose weight. So, commit to doing some kind of workout five to six days a week for at least 20 to 30 minutes. You’ll see positive effects from both aerobic and strength training exercises. But remember, check with your doctor before you start any exercise regimen.

Insights: Diabetes and Insulin Therapy

DR. HOLLY ATKINSON
Welcome to HealthiNation. I’m Dr. Holly Atkinson. For many diabetics, insulin therapy is the best method of treating diabetes, but some patients resist insulin treatment. I sat down with Dr. Derek LeRoith, Chief of the Endocrinology, Diabetes and Bone Disease Department at the Mount Sinai School of Medicine to talk about some of the issues involved and what’s on the horizon that could help make insulin therapy easier for patients.

DR. DEREK LEROITH
There used to be a big fear for patients about going onto insulin. We try to educate the patients today that actually taking insulin is not such a bad thing. If they really look at what the problem is, the fear of the needle is no longer a major fear. The needles are so small and painless that injecting yourself is actually quite straightforward. And there are now long-acting insulins that can be introduced with one injection a day. There are actually pens that individuals walk around [with] in their pockets just like a regular pen. You take it out, you inject through the clothing, you don’t get infections and nobody notices … they take the injection that way. So, insulin injections should not be feared. The biggest problem that patients have, particularly when they’re on insulin, is that they have to check their blood sugars quite often. And that’s much more painful than the injection.

DR. HOLLY ATKINSON
So is there anything on the horizon in terms of new devices to check blood sugar that doesn’t necessitate that painful prick?

DR. DEREK LEROITH
The whole concept of many of the biotech startup companies and many of the larger companies is “what can we do to make life easier for the diabetic?” And not sticking your finger would be a great advance. So there are now devices that either have a needle that goes under the skin and sits there for three or four days and monitors the blood sugar as often as you like. Or, in fact, some companies are trying to work on a non-invasive technique where you don’t actually have to introduce a needle, but you read it from the outside. [This] makes it much more convenient and less painful.

DR. HOLLY ATKINSON
This is actually a question from Sarah, who is a type 1 diabetic. She says:

“Any advice for avoiding the rollercoaster type 1 diabetics can find themselves in – highs then lows then highs again?”

DR. DEREK LEROITH
So, that’s a very complicated [question] because type 1 diabetics have this rollercoaster for many different reasons. The best thing to do of course is consult with her physician; make sure that her gastro-intestinal tract is not the cause for this. Sometimes patients are using the pump, which allows them to control their blood sugar a little better. They may have to investigate some of the hormones that help keep the blood sugar up when it drops too low. The best advice is to consult with a diabetologist.

DR. HOLLY ATKINSON
So here’s the insight. Insulin therapy is a very effective way of controlling diabetes. For some patients it’s a must. And while the finger sticks are painful, they are well worth it given the numerous benefits you get from controlling your blood sugar. The good news is that in the not-too-distant future, new devices will make injecting insulin less painful and, importantly, make checking your blood sugar easier.

Insights: Diabetes Cure?

DR. HOLLY ATKINSON
Welcome to HealthiNation. I’m Dr. Holly Atkinson. There is a lot of promising research that is happening in the diabetes world. But will any of it lead to a cure? Dr. Derek LeRoith, Chief of Endocrinology, Diabetes and Bone Disease Department at the Mount Sinai School of Medicine, shares his insights.

Why is diabetes so bad?

DR. DEREK LEROITH
Because, diabetes affects virtually every organ of the body. Every tissue is affected. Patients with diabetes develop complications, which can affect the eyes, the kidneys, [and] the heart. They even develop more cancer than the normal population. And since this is a growing epidemic throughout the world, we’re going to see more and more of these complications.

DR. HOLLY ATKISON
Do you think patients really understand how severe the complications can be? Have we gotten that word out?

DR. DEREK LEROITH
No, I don’t think so. I think patients actually try to avoid thinking about these complications because if they were aware of them and we were able to educate them about them, perhaps they would take better care of themselves.

DR. HOLLY ATKINSON
Let’s say you have an ideal patient who does absolutely everything right? Can they reverse their diabetes?

DR. DEREK LEROITH
Reversing diabetes is an interesting term. Can you change things? No. You will always be a diabetic, but your blood sugar can be perfectly normal. So we have individuals who are so particular about their diet and weight that they in fact don’t take medication because their weight is perfectly normal and they don’t eat simple sugars that raise their blood sugar after their meal and if you measure the hemoglobin A1C over a year or two, it’s always in a normal range. So there are some patients like that. But it’s the exception.

DR. HOLLY ATKINSON
We’ve heard a lot about the effects of bariatric surgery and some people even suggest that it’s a cure.

DR. DEREK LEROITH
Bariatric surgery has been shown to be very helpful in reversing the high blood sugars and bringing the A1Cs down into a normal range … in fact even taking patients off medication because their blood sugars are now normal. So it reverses the diabetic state, but it doesn’t cure diabetes because in fact if you wait five or six years and you watch the outcomes of many of those patients, some of them either put on weight and in some of them, the high blood sugar returns. And the reason for that, we believe, is even if you keep your weight off, years later the beta cell, the insulin producing cells, may in fact still deteriorate. So in many of those cases, the diabetes would come back and would require medication. So I don’t like to call it a cure.

DR. HOLLY ATKINSON
We got some questions from some people with diabetes. Sarah asks:

“We’ve heard a lot about islet cells, stem cell research, etc., but are we any closer to finding a real cure for type 1 diabetics?”

DR. DEREK LEROITH
The cure by finding stem cells, which will develop into islet cells, is a long way off. The main reason is, to get a supply of stem cells that we can then give to the type 1 diabetic by injecting, say, into the liver, where it will produce insulin and they’ll come off their insulin needs [is difficult]. The problem with that is, rejection [of those stem cells] by the patient. We really have to find good preventative medication that will prevent the rejection. And people are working on both – developing the islet cells, either through stem cells or other means, and there are people who are testing the prevention side. When those two come together, we’ll be able to say we’ve cured diabetes.

DR. HOLLY ATKINSON
What are the burning questions that you would love to have answered about diabetes that you don’t have right now.

DR. DEREK LEROITH
Well, I don’t know what causes diabetes. We know it’s genetics, we know that people have found certain genes, but what we’d really like to know is, how do these genes interact? Because if we understand more about the genetic background … we certainly understand a lot about the environmental effect, with overweight, obesity driving the diabetes. But if we knew more about the genetics, we’d understand more about where to target the new therapies. I’m looking for the gene targets that can improve the medications that we could derive in the future for our diabetic patients.

DR. HOLLY ATKINSON
And how far off do you think success is in that area?

DR. DEREK LEROITH
I hope that in my lifetime we will have some success.

DR. HOLLY ATKINSON
So here’s the insight. The complications of not treating your diabetes properly can be severe. So hopefully this knowledge will help you take control of your health by committing to keeping your blood sugars under good control. And while bariatric surgery is not a cure for diabetes, it is an important treatment option for those who are having difficulty losing weight and lowering their blood sugar. A cure for diabetes maybe a long way off, but there is promising research being done every day.

HealthiNation offers health information for educational purposes only; this information is not meant as medical advice. Always consult your doctor about your specific health condition.

Last Review Date: June 30, 2010

Reviewed by: Dr. Holly Atkinson

Reviewed by: Dr. Preeti Parikh