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Video Transcript: Diabetes

Part One:

Ellen Beth Levitt: Welcome to Maryland Health Today. I'm Ellen Beth Levitt. More than 20 million people in the United States have diabetes. But with advances in understanding and treatments, there are many new options to help them successfully manage the disease, and we'll learn about them on the show today. My guest is Dr. Tom Donner, a diabetes expert and director of the Joslin Diabetes Center at the University of Maryland Medical Center. Dr. Donner is also an associate professor of medicine at the University of Maryland School of Medicine. Welcome to the show.

Thomas W. Donner, M.D.: Thanks for inviting me.

Ellen Beth Levitt: First of all, could you explain what is diabetes?

Thomas W. Donner, M.D.:Diabetes is a disease of elevated sugar in the bloodstream, sugar called glucose.

Ellen Beth Levitt: I guess there are different types, right?

Thomas W. Donner, M.D.: That's right. There are two main types of diabetes: Type 1 and Type 2. These are different in terms of how they start. We think of type one in children also in persons who are thin or losing weight. They have diabetes because their body stops making insulin. Type two diabetes is a condition typically seen in adults, those who are overweight, strong family history of diabetes. They have difficulties with the insulin not working well. And so while there may be plenty of insulin around, the blood sugars are still increased because the insulin is not working properly.

Ellen Beth Levitt: Could you tell us more about the role of insulin? Our bodies produce insulin and then what is its role.

Thomas W. Donner, M.D.: Insulin is a hormone. It's made in the pancreas of the body. Pancreas is an organ in the abdomen. And insulin is released into the bloodstream, and it travels through the blood to all tissues in the body. We think of insulin as a key that unlocks the door to allow sugar or glucose in the blood to enter into tissues where it's used as energy.

Ellen Beth Levitt: Is this sugar that comes from what we eat or is it a natural sugar that the body produces?

Thomas W. Donner, M.D.: It comes from both forms. we eat foods. and also starches that we eat, they get broken down by the body into sugar. So the sugar levels go up in the bloodstreams. but our body produces sugar. and also release it into the bloodstream.

Ellen Beth Levitt: Why is it so important to regulate sugar?

Thomas W. Donner, M.D.: High levels that are high for a long time can cause problems.

Ellen Beth Levitt: What kind of problems?

Thomas W. Donner, M.D.: I want to preface the fact that these complications are preventable. But diabetes remains the leading cause of blindness in the U.S. in adults; the leading cause of kidney disease in the United States; leading cause of amputation. If you look at dialysis clinics in the state of Maryland, about 45% of the people who are on dialysis have it in part because of diabetes.

Ellen Beth Levitt: It also contributes to heart disease and stroke.

Thomas W. Donner, M.D.: Diabetes is risk factor of heart disease and stroke, upwards of two to four fold increased risk of those complications.

Ellen Beth Levitt: If you have too much sugar in the blood, does it do damage the organs?

Thomas W. Donner, M.D.: That's right. It's a complicated process. but sugars will tend to hook on to proteins. They're the building blocks of all tissues in the body. It causes them to become less flexible and changes their function. So blood vessels get affected by high blood sugar. Blood vessels can get clogged up from high sugars for a long period. And they also become leaky so we see changes in the eyes because of things leaking out of the blood vessels in the eyes.

Ellen Beth Levitt: And it's because you don't have enough insulin produced by your body has stopped producing or the insulin's not working.

Thomas W. Donner, M.D.: That's exactly right.

Ellen Beth Levitt: So, what is hypoglycemia?

Thomas W. Donner, M.D.: When we talk about elevations in blood sugar, it's hyperglycemia. Hypoglycemia would be a low blood sugar reaction.

Ellen Beth Levitt: What would be the symptoms?

Thomas W. Donner, M.D.: Hyperglycemia, a number of symptoms of high blood sugar, typically when it's significantly elevated, so patients will start becoming thirsty. They're notice that they're urinating more frequently. It's hard to recognize how much you urinate in the day, but people remember how many times they have to get up at night. They may be thirsty at night. The symptoms can be very subtle. They can simply be tiredness.

Ellen Beth Levitt: Are there any symptoms of diabetes then?

Thomas W. Donner, M.D.: Right. Unfortunately, as we talked about earlier, diabetes can have no symptoms at all. Patients may not really notice any symptoms at all. That's a problem because they can develop complications.

Ellen Beth Levitt: So there are about 20 million people that have diabetes that we know have diabetes, but there could be more that haven't been diagnosed.

Thomas W. Donner, M.D.: That's right. then, there's a condition called Pre-diabetes. Their blood sugar levels are on the high side, but not enough to be called diabetes. That's about 41 million persons in the United States. This graph shows how rapidly the rates are increasing in the United States. On the left side in 1990, you see the light blue is at about four or five percent rate. On the right side in 2001, you can see the dark blue is about 7-8% of the population having diabetes. In some states, such as Mississippi, Alabama, Florida, the rates are over 10%.

Ellen Beth Levitt: Why do they have the highest rates?

Thomas W. Donner, M.D.: If you put a graph like this of the United States and showed obesity rates, they would be similarly high in those states. Those states have the highest obesity rates. Plus, states like Florida, there's an older population. And diabetes is also a disease that increases in frequency as people get older.

Ellen Beth Levitt: How does Maryland stack up?

Thomas W. Donner, M.D.: Maryland is about in the middle. We're about in the middle of the U.S. population.

Ellen Beth Levitt: Why do you think the rate is going up so dramatically?

Thomas W. Donner, M.D.: I think most of us believe that the main cause is that we as a population are becoming heavier and less physically active. As we become more advanced technologically, we don't have to do as much physically. We work at our desks for much of the day. Even the children are spending more time in front of the television playing video games. So inactivity is a major contributor to the development of diabetes.

Ellen Beth Levitt: Do we know why there is that connection?

Thomas W. Donner, M.D.: Exercise stimulates the muscles to work. And muscles that are exercised take sugar out of the bloodstream much better. It also sensitizes the body to insulin more. So, muscles become more sensitive to the insulin that's around.

Ellen Beth Levitt: You mentioned symptoms earlier, do these symptoms come on suddenly or is it a gradual process?

Thomas W. Donner, M.D.: It may be sudden, especially in type one diabetes when the body's ability to make insulin fails pretty quickly and blood sugars rise rapidly. The symptoms come on relatively quickly. Patients may just get a history of frequent urination, increased thirst, blurred vision, tiredness for a couple of weeks. Whereas other patients, typically type two patients, who have more mild elevations of blood sugar may have very mild symptoms that only become more prominent when their blood sugars goes higher later in life.

Ellen Beth Levitt: The type one diabetes, is that really strike in childhood?

Thomas W. Donner, M.D.: So, type one diabetes is primarily a disease of children before adulthood. But we also know that many patients who are adults in your 30s, 40s, and 50s can develop type one diabetes. So, we're sometimes challenged to figure out what type they have, but there are now blood test that we can now do that can measure the immune system that attacks cells in the body that make insulin. We can measure those antibodies and determine whether they have type one or two.

Ellen Beth Levitt: Is that what is believed to be the cause of type one? That your body produces antibodies against the normal process?

Thomas W. Donner, M.D.: Yes. We don't know why, but it's an autoimmune disease. We don't know what triggers it. But, for some reason, the immune system is triggered to begin attacking cells in the body that make insulin.

Ellen Beth Levitt: You were talking earlier about complications that can arise from untreated diabetes. And I know that you were part and the University of Maryland was part of a large landmark study in the 90s that showed that serious complications can be prevented with good control of sugar or glucose.

Thomas W. Donner, M.D.: That's right. You're referring to a study called the DCCT, or Diabetes Control and Complications Trial. This actually started in the mid-1980s. At that time, physicians were happy if the patients weren't having terrible symptoms from high blood sugar, not having low blood sugar reactions. That was okay to have a blood sugar in 180-200 range. that was the standard of care. Whereas, we knew the complications were probably caused by high blood sugar. So a study was done, and in those patients who were more aggressively treated after six years had a dramatically lower rate of complications in the eyes, kidneys and the nerves.

Ellen Beth Levitt: What do people need to do? How often should they check their blood sugar and are there some things they can do that are relatively simple in terms of life style modifications?

Thomas W. Donner, M.D.: When you talk about type one and type two, the treatments are very different. In patients with type one, they need to be on insulin from the start. I'm going to talk first about type two diabetes, because that's 90% of people. Initially, education in terms of lifestyle changes that can be made especially through diet and exercise is the cornerstone of treatment in those patients. In general, patients of type two diabetes are carrying extra weight and if they lose even a modest amount of weight, their blood sugars may come back down to normal.

Ellen Beth Levitt: That's pretty good. what are some of the other things that they can do?

Thomas W. Donner, M.D.: Also encourage increased exercise. it can be a challenge. Even modest exercise, we're talking about 20 to 30 minutes of exercise each day.

Ellen Beth Levitt: Even fast walking or gardening.

Thomas W. Donner, M.D.: Exactly. But maybe not gardening. that is some physical activity, but more like walking, jogging, biking.

Ellen Beth Levitt: Swimming maybe.

Thomas W. Donner, M.D.: Swimming is an excellent exercise. The effects of exercise not only help blood sugar while you're exercising, but hours afterward, the body is more sensitive to insulin. It's not more active for several days. 20 or 30 minutes a day has been shown to dramatically reduce the rate of developing diabetes in people.

Ellen Beth Levitt: What does someone have to do every day?

Thomas W. Donner, M.D.: We'll talk about type one patients. We have them check their blood sugar at least once a day. For a number of reasons. If a physician has recommended them to do diet and exercise, they can see what the effects are. So it's very rewarding when patients exercise one day and the next day they see that their blood sugar is down. Also, if they've eaten a large meal one night, they'll see their level very high the next morning. So, finger stick testing is important. Again, adhering to a diet prescribed by the nutritionist or doctor and exercise are the cornerstones.

Ellen Beth Levitt: Is it important to keep blood pressure and cholesterol level in check?

Thomas W. Donner, M.D.: Absolutely. So, the way we prevent complications of diabetes are through good blood sugar control and through tight control of both the blood pressure and cholesterol.

Ellen Beth Levitt: You brought some tools with you to show us what people with diabetes need to use. So, if you could show us.

Thomas W. Donner, M.D.: Many people may not be aware that we have small devices now that can measure the glucose. Here i have another one. These devices are easy to use. I have a glucose test trip that you insert at the top. After sticking the test strip in, then--

Ellen Beth Levitt: You would have a little drop of blood on the strip.

Thomas W. Donner, M.D.: That's right. This lancet has a very small needle. And it can be adjusted how deep the needle goes into the skin. You press this and push a button and a very small needle pricks the finger and a drop of blood comes out. The patient puts the blood up to the strip, within five seconds, you'll get a blood sugar reading.

Ellen Beth Levitt: You have to learn what these numbers mean.

Thomas W. Donner, M.D.: That's right.

Ellen Beth Levitt: It's a lot of education.

Thomas W. Donner, M.D.: Our goal is to keep the levels in as close to normal range without causing any complications. We instruct patients on what those levels are. if a patient is on insulin, the blood sugar, we have them do at least four test a day. And the reason is because if their levels are on the high side, they can use a little extra insulin to get their blood sugar back to a normal range.

Ellen Beth Levitt: Great. We have to take a break. Stay with us.

Part Two:

Ellen Beth Levitt: Welcome back to Maryland Health Today. I'm Ellen Beth Levitt. My guest is Dr. Tom Donner.He's a diabetes specialist and director of the Joslin Diabetes Center at the University of Maryland Medical Center. Dr. Donner is also an associate professor of medicine at the University of Maryland School of Medicine. Before the break, we started talking about the importance of testing blood sugar if you have diabetes. How often do people need to test their blood sugar?

Thomas W. Donner, M.D.: It depends on what the treatment is. If it's just diet and exercise or pill therapy, once a day is adequate, especially if the levels are in a good range.

Ellen Beth Levitt: That's if you have type two.

Thomas W. Donner, M.D.: Yes. If you have type two.

Ellen Beth Levitt: And in that case, your body is just not using insulin efficiently, right? You do have insulin circulating.

Thomas W. Donner, M.D.: Yes. So, if diet and exercise alone don't work, we can use the medicine that help the body make more insulin or to make the body more sensitive to the insulin that's around.

Ellen Beth Levitt: In addition to diet and exercise, can stress or other factors contribute to high blood sugar levels?

Thomas W. Donner, M.D.: Certainly, stress is something we can't measure. It's clear that stress increases the factors. I had a patient that i invited to talk to some of our first year medical students about type two diabetes. She had levels of about 100 before speaking and after speaking she tested again and her levels went up to 200 because of the stress of having to sit in a classroom of medical students.

Ellen Beth Levitt: What are normal blood sugar levels? You mentioned 100. Is that something to strive for?

Thomas W. Donner, M.D.: I think 100 would be great. Patients without diabetes before eating have blood sugar levels typically between 70 and 100. And the blood sugar doesn't go over 140 after eating. So, those are our targets to try to get patients close to normal. We like to keep them under 160 after eating.

Ellen Beth Levitt: Interesting. Are there certain foods patients need to avoid? I've heard to stay away from sweets and candy.

Thomas W. Donner, M.D.: We try not to tell people to stay away from a certain food because that makes them want it more. Small amounts of sugar, especially when it's eaten at the same time with a meal, it's not bad. It's part of the overall balance. If you want cake at a party, you have to watch the starches that you eat during the meal.

Ellen Beth Levitt: I guess you have to balance it out.

Thomas W. Donner, M.D.: That's right.

Ellen Beth Levitt: Are there newer devices to monitor the blood sugars?

Thomas W. Donner, M.D.: Sure. The finger stick devices have gotten very quick and very accurate. But, they still require multiple finger sticks during the day. So some patients with type one diabetes, especially pregnant patients need to test their blood 7-10 times a day. there's a little bit of pain in that.

Ellen Beth Levitt: Sure.

Thomas W. Donner, M.D.: We now have two companies with devices approved for continuous blood sugar monitoring. These devices are small. They have a small catheter that goes under the skin and can stay there for up to 7 days. They give updates every five minutes. Not only will it show the levels, it will also show what level the blood sugar is ?and what direction the blood sugar is heading.

Ellen Beth Levitt: So it will show a trend.

Thomas W. Donner, M.D.: Exactly. If a patient has a good blood sugar level at bedtime, they may eat a snack because they say well my blood sugar is normal, what if it goes down. If they've seen for the last hour, if they are very steady, they probably wouldn't eat that snack at bedtime.

Ellen Beth Levitt: So you keep it for seven days?

Thomas W. Donner, M.D.: Right, and then a new sensor has to be put in.

Ellen Beth Levitt: Does it keep a record of several days?

Thomas W. Donner, M.D.: Most of the devices will show the last nine hours, but you can also download these devices onto a computer graphic and it can print out your blood sugar levels for many weeks!

Ellen Beth Levitt: That's amazing.

Thomas W. Donner, M.D.: Right, the technology.

Ellen Beth Levitt: Many people are on insulin pumps so they don't have to give themselves the shots.

Thomas W. Donner, M.D.: That's correct. This is mainly for the people with type one diabetes and it has an insulin cartridge in it. The insulin is given slowly. Or the patient can tell the machine to give them a boost right before a meal.

Ellen Beth Levitt: Are there any devices that would have the continuous glucose monitor and the insulin pump work together letting the patient know that the person needs more insulin right now.

Thomas W. Donner, M.D.: Yes. As you can see on the graphic right now. This device has both a sensor and a pump. is sensor actually tells the patient what the blood reading is and it tells it to the pump but the patient still has to use that number and tell the pump how much insulin to give.

Ellen Beth Levitt: So the person still has to use their judgment and get involved.

Thomas W. Donner, M.D.: That's right, the exciting thing is that if we had a computer program that allows the information to go to the pump and let the machine know how much insulin to deliver. that would be great. That would be an artificial pancreas.

Ellen Beth Levitt: Is that coming?

Thomas W. Donner, M.D.: I think it is. It's not going to be over the next few years, but i think in the future that will be available.

Ellen Beth Levitt: Are you doing clinical studies on these new technologies?

Thomas W. Donner, M.D.: We are. There is a company in Maryland that has a micro chip that will measure sugar. We'll be testing it this fall. a sensor that goes under the skin and radios to a watch device what the levels are at this time. This sensor can stay in for 3-6 months in animal models.

Ellen Beth Levitt: Well, that would be a wonderful advance if it pans out.

Thomas W. Donner, M.D.: As with many of the patients, I think it's important for the patients to do the finger pricks to make sure they are getting the accurate information.

Ellen Beth Levitt: Sure. We only have a couple of minutes left --

Thomas W. Donner, M.D.: Sure.

Ellen Beth Levitt: But I wanted to ask you about the patients with type two diabetes. What about the pills?

Thomas W. Donner, M.D.: We have pills that can be used in combination if one alone doesn't get the blood sugar under control. The newer medicines are actually quite safe. So we see much less in the way of low blood sugar reactions, stomach side effects, which can be seen with some of the medications. But again, if the person doesn't tolerate one well, we have options now.

Ellen Beth Levitt: Can you talk about your Joslin center and what it involves?

Thomas W. Donner, M.D.: At the university of Maryland Diabetes Center, we have diabetes specialists. We have educators, who teach patients how to use these devices and how to eat healthy. We have nutritionists. We have psychologists. We have eye doctors. We have podiatrists who take care of the patient's feet- all seen in the same center. So it's very easy for us to talk to one another and to guide a patient to one of the other experts if they need it.

Ellen Beth Levitt: I guess these are all services that the people with diabetes should take advantage of so they can live a healthier and hopefully a longer life.

Thomas W. Donner, M.D.: Sure, especially the education component. They may not need to see all of the specialists that we have, but especially the education component is extremely important.

Ellen Beth Levitt: There's a lot to learn. Thank you.

Thomas W. Donner, M.D.: You're welcome.

Ellen Beth Levitt: My guest has been Dr. Tom Donner. He's a diabetes specialist and director of the Joslin Diabetes Center at the University of Maryland Medical Center. and Dr. Donner is also an associate professor of medicine at the University of Maryland School of Medicine.

If you have any comments or questions about this program, please contact me by email at eblevitt@umm.edu.

If you'd like to reach Dr. Donner or any other University of Maryland physician call 1-800- 492-5538. Or, visit the web site, where you'll find a great amount of health information and be able to see other Maryland Health Today programs. The address is www.umm.edu.

Take good care of yourself.

We'll see you next time for Maryland Health Today.

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This page was last updated on: January 7, 2009.

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