Diabetes Basics
What is "diabetes"?
Diabetes is a disease that means the blood sugar levels in the blood are too high. And the reason that's important is because all of us need some blood sugar in our blood; that's how your brain gets fuel, gets energy. Sugar is necessary. It's energy. But in diabetes, what happens is the blood sugar levels go way too high. And that means two things for a person with diabetes: one is the body doesn't get enough energy, and second of all, it means that that high blood sugar level caused by diabetes starts causing damage, and over time it damages the eyes, the kidneys, the nerves, and can cause really serious complications. Treating diabetes means lowering the blood sugar levels and then keeping them normal forever.
What is the difference between "type 1" and "type 2" diabetes?
There are two kinds of diabetes and it's very important that people know what kind they have if they have diabetes, and even what kind of diabetes they are at risk of getting. Type 1 is the least common kind and we used to call type 1 diabetes 'juvenile onset diabetes' because we only thought kids got it. However, in my practice, I've seen people as old as 94 years get type 1 diabetes, because what type 1 diabetes means is that there is an abnormal response in the body. The body makes what we call antibodies (the infection-fighting cells), that destroy the Beta cells (the insulin-creating cells) in the pancreas so the body stops making insulin. When you have type 1 diabetes, you must take insulin injections for the rest of your life. That's what type 1 diabetes means; not making enough insulin, meaning the body can't use the sugar that's in your blood. Type 2 diabetes is by far the most common kind. It's a world-wide epidemic. It is really one of the most serious diseases of our time. In many cases type 2 diabetes occurs in people who have a family history of diabetes, and it also occurs because many people develop it as they gain weight and become sedentary. We used to call it 'adult onset diabetes' because we thought that older people got it, but the oldest case I know of adult onset diabetes is in a two-year-old. So, we know that age doesn't really matter. What matters, in many cases, is one's habits; one's health habits. That is, whether one keeps fit and active and takes care of themselves, or over time becomes heavier, less active, and then develops type 2 diabetes.
Can a person have both type 1 and type 2 diabetes?
It turns out that you can have both 1 and type 2 diabetes. In order to understand this, though, you actually have to understand a little bit more about type 2 diabetes, because type 2 diabetes is probably an adaptation for survival. It probably is a set of genes that helped our ancestors to survive famine, because back in the old days we didn't have food everywhere. We went through periods of eating and then fasting: literally not having food for weeks. Therefore we needed to store fat very efficiently. The place that our bodies store fat the best is right in the centre, and that's called central obesity. That storage form of fat is right there, right next to your liver, your pancreas and your stomach, and it's great. It immediately can put sugar back into your blood if you're starving. However, if you're living in a society, like our modern societies, where food isn't an issue for most people (not everybody, but for most) that central fat just grows and grows, and now instead of becoming a good thing it becomes a bad thing. All that fat by your liver causes it to make abnormal cholesterol particles and causes it to become inflamed; all these things start happening that cause diabetes but also the risk for heart attack and stroke. So people with type 2 diabetes and central obesity, and that's most people with type 2 diabetes, have a risk for heart attack and stroke. So, you can have type 1 diabetes, meaning your pancreas doesn't work anymore because it was attacked by antibodies, and you can come from a family where, say, your mother or father had type 2 diabetes; you can have central fat, high blood pressure, abnormal cholesterol levels and it means you have both type 1 and type 2 in a way. However, what's really important is not the names 'type 1' and 'type 2', but that if people have central fat, they need to be extra careful to avoid having heart attacks and strokes.
What causes type 1 diabetes?
Type 1 diabetes is probably caused by something genetic, meaning there's something in one's background that makes one at risk. We're looking for the kinds of genes that cause Type 1 diabetes. But then something has to happen that triggers the autoimmune response. So we think it's a chemical, we think it's in the environment, but we don't know what. But we know that, for instance, you can have an identical twin with the same genes you do and not everyone is going to get Type 1 diabetes. Less than half will end up getting Type 1, because it's some environmental trigger.
What causes type 2 diabetes?
Type 2 diabetes is a set of genes that are present in the wrong environment. So 50 years ago, we weren't having an epidemic of Type 2 diabetes and yet 50 years ago, we had the same genes. So what's happened in the past 50 years? Well, food is incredibly abundant. Not only food overall but refined food. So we have all this excess of things that have white flour and white sugar and everything else that gets absorbed in our bodies very quickly and our bodies don't know how to deal with. The second thing is we are not exercising. It is not just that we are not exercising in our leisure time. In fact, leisure time activity has not changed that much but what we are not doing is exercising at work. Most of us when we go to work just sit at a computer or sit at a desk. Compare that to the turn of the century 100 years ago when people were very active in their jobs. So, we decreased exercise and we've increased caloric intake, so people are becoming more resistent to insulin and that starts to lead to Type 2 diabetes in people who are at risk. Now, let me point out that not everyone is going to get Type 2 diabetes. You can get really fat and not get Type 2 diabetes unless you are genetically prone to get it.
Who is most likely to get type 2 diabetes?
People who are the most genetically prone to get type 2 diabetes are African Americans, Latinos, Asians, and Native Americans. There's a fairly large list, but the most important thing is to know your family history. I see lots of Eastern Europeans who have type 2 diabetes that runs in their family. So, if you have anybody in your family that has diabetes of any type, that means that you're at risk for getting it yourself. The other thing, though, that I think is incredibly important is that we can prevent type 2 diabetes if it's picked up early. So, anybody who has a child with a risk for type 2 diabetes, anyone with a history of type 2 diabetes in themselves, needs to look at their kids. What we're seeing now is that parents who have diabetes are passing it to their children, and their children are getting it at younger and younger ages. So, I look at this as a family disease, and everybody in the family needs to be involved in having a healthier lifestyle, eating better, and basically preventing type 2 diabetes from happening.
How is food used by the body and what is "glucose"?
When you look at food, there are three different types that we commonly consume. We consume carbohydrates, fat and protein. Carbohydrates become sugar in the body. Carbohydrates are starches. They're simple sugars. It's honey. It's an apple. It's a piece of bread. It's anything white, more or less, but it really is a lot of the different kinds of food that we eat. When you eat carbohydrate it goes into your bloodstream and it gives you energy. It gives you energy to run a race. It helps you learn, think and read or do mathematical equations. It's the body's fuel. Without glucose, without the ability to have glucose in your blood, you would die. It is vital to life. Fat on the other hand, is a stored form of fuel. In essence, both fat and protein can be broken down into sugar. So, sugar is what we all need to exist, to live our lives, and to have energy. Our bodies are very clever about sugar. For instance, say you decide, “I'm not going to eat any sugar.” If you don't have diabetes and you're normal, what would happen is your body would start making sugar. You can make sugar from your liver. You can bring up sugar from your muscles. You can break down stored glucose, for instance, glycogen that's in the muscles or in the liver. Your body has an incredible ability to maintain normal sugar levels so that we exist.
What happens to my body after prolonged exposure to a high blood sugar level?
High blood sugar levels are very, very toxic to the body, but before I use words like 'high,' I want to define 'high'. So a normal blood sugar, I say, is a hundred. It's an easy number to remember. There's a range around a hundred but most of us, most of the time, have blood sugar levels around a hundred, and that's what you expect. That's what you want. When you have diabetes, your blood sugar levels can be two hundred, three hundred, four hundred; very high. When your blood sugar levels get to be above three hundred you feel very thirsty, dehydrated, you start urinating a lot, your eyes may get blurry, and you don't feel right. High blood sugar levels, say they go up high to three or four hundred, will make you feel sick. The problem, though, is that most of the time people who are getting diabetes have blood sugar levels that are around two hundred and they don't feel sick. In fact, most people have diabetes for five to seven years before they're diagnosed. So, many people are wandering around who have diabetes and don't even know it because they have no symptoms. That blood sugar of two hundred, though, is causing damage. It's damaging the back of the eyes, the nerves, the kidneys, and the heart. All of that is susceptible to this damage from the sugar. We don't exactly know why and how sugar damages these vital organs but we know it does, and we know that lowering blood sugar levels to normal takes away the risk for those complications.
Does type 1 diabetes only occur in childhood?
Type 1 diabetes means that the body's immune system has attacked the insulin producing cells in the pancreas, called the beta cells, and basically rendered them killed; they're destroyed. We used to think that type 1 diabetes just happened in children, but we now know that it happens at any age. We've seen babies as young as just a couple weeks old getting type 1 diabetes, and my oldest patient with type 1 diabetes is 94 years old, so it really fits across the age spectrums. Type 1 diabetes is still probably more common in childhood, but certainly anyone, at any age, can develop type 1 diabetes.
Is one type of diabetes worse than the other?
Diabetes is a very serious disease, and contrary to what many, many people come to me saying, there is no such thing as a "little diabetes." Diabetes is diabetes is diabetes. It is deadly, and if you don't treat it, it is like cancer. Trust me, I have seen people die from it in their 20s and 30s. I've seen blindness, amputation. I have seen horrible things from diabetes; things that I don't even want to remember. So, untreated diabetes is very bad. I don't think that there is any bad or worse between type 1 and type 2, and I specifically think that if you treat diabetes, you can avoid most of the complications. Therefore, I look at it from a more positive perspective. This is a treatable disease. It isn't cancer. It is not invariably fatal, and both types are equally treatable. So I don't think one is worse than the other, but I think ignoring it is the worst thing of all.
Diabetes Detection
Is type 1 diabetes genetic?
Most of the time when I see someone with type 1 diabetes, I don't usually think they're going to have a family member with it. If they do, it's going to be something very distant. So, we know that there is a genetic component to type 1 diabetes, but there is also an environmental component. Something happens that we don't understand really; some trigger, something toxic, something chemical, or something viral, that creates the diabetes and creates the destruction of the insulin creating cells in the pancreas. I do have, rarely, families where there's two siblings with type 1, but it's not that common.
Is type 2 diabetes genetic?
With type 2 diabetes I always say, who else in your family has this, because it is so genetic. And even though there's this huge environmental component, so that the genes that cause type 2 diabetes if you live in rural Mexico and you're out in the field working, you're not going to have diabetes. But if you and your sister move up to LA, you're going to end up getting diabetes because suddenly you're no longer working in the fields, you're much more sedentary and you're eating a lot more food and in particular a lot more junk food. So type 2 diabetes, the way I look at it, is almost always found in families. The corollary to that is: if you have type 2 diabetes make sure you watch out for your kids and your siblings and even your parents, because I see it up and down in families. I'll see somebody who gets it in their forties who will then find out that their mother has it and who will look at their kids and try to figure out how to keep their kids from getting it; so this is a family disease.
What are the symptoms of type 1 diabetes?
Type 1 diabetes is often found in people where they become really thirsty. It's not generally a subtle thing: their blood sugar levels become very high, say 300 or 400, and considering normal is about 100, that's very high. They'll get thirsty, they'll urinate a lot, they'll feel tired, and they'll lose weight; they're kind of the classic symptoms of someone getting type 1 diabetes. Now, when kids get type 1 diabetes, they tend to seem really sick. They get a lot of symptoms; they get thirst, they get dehydration. The parents will really notice there's something wrong with their child. When people, though, get type 1 diabetes as an adult, they actually might not have symptoms. They may not really have symptoms at all until their doctor picks it up on a routine blood test. So, at least from my own experience, adults getting type 1 diabetes may end up not having symptoms; it would end up as being something they found out from their doctor. So, don't assume that a lack of symptoms means you don't have type 1 diabetes. You could be getting it and just not know it yet.
What are the symptoms of type 2 diabetes?
In the vast majority of cases, people with type 2 diabetes have no symptoms and that's a big problem, because just because they don't have symptoms, doesn't mean there is not harm going on. In fact, all of the time that they're having high blood sugar levels and not knowing it, they're developing complications of diabetes. So that it's very important if someone's at risk, if they have a family history of diabetes, if they're overweight, particularly in the center. If they have high blood pressure. If they have abnormal cholesterol levels. Those people need to go every single year and get a fasting blood sugar test at their doctors, to be sure that they don't have it.In the United States we estimate that most people have diabetes for 5 to 7 years before it's diagnosed. So that's why people need to know to go in. Now, that being said, there are things that people might notice. As I said, gaining weight in your center, really good sign that you're at risk for diabetes. Another thing is a syndrome called Polycystic Ovarian Syndrome that women get where they have irregular menstrual cycles. They may have increased facial hair, problems with fertility. Those people are actually at high risk for getting diabetes. A woman with high blood sugar levels may complain of frequent vaginal infections. People may complain of wounds not healing quite as well. They might be a little more tired. Their eyes might be a little more blurry and even people with type 2 diabetes can get that excessive urination, thirst and weight loss. But that's very, very few. Most people don't know that they're sick until it's picked up in a doctor's office.
What tests detect diabetes?
The good news is that it's really easy to detect diabetes, because it's a disorder of blood sugar. We know that a normal blood sugar is 100 or less. So, if you go in to see your doctor, and you haven't eaten anything overnight, you have, what we call, fasted for twelve hours (you can have water). They check your blood sugar, and if it's between 100 and 125, it means you have pre-diabetes, or you're someone who's on the way to get diabetes. If your blood sugar is 126 or more, it means you have diabetes. Now, in medicine, we never do anything once, so we say that if your number's abnormal, you need to go back in and have it rechecked so that we can make sure that that's truly the diagnosis. It's more important to me, though, that people know that they're at risk. Say your blood sugar's 112 this year and then it becomes 126 next year. What's happening is that you're just gradually getting worse and worse, and what you want to do as an individual is to change whatever you can change, or take medication, so that the disease doesn't get worse.
How often should I see my doctor if I have diabetes?
When people have diabetes, they need not only to go to their healthcare provider more frequently, they actually need to really take charge of their healthcare because the beauty about diabetes is it's numeric. So we tell you what your blood sugars needs to be and we also tell you what your average blood sugar over three months should be and there's a test called the Hemoglobin A1c that tells us what your blood sugar is. It tells you what your blood sugar is. You also need to manage your cholesterol levels, your good and bad cholesterol levels and your blood pressure. Most people worldwide don't get close to the kind of medical care they should for their diabetes and it's in part because diabetes doesn't hurt. So you go to your doctor because your back hurts and your doctor has ten minutes to spend with you. At the end of that, they are not going to have talked about your blood pressure and your blood sugar and all these other things you need to do to live long and healthy with diabetes. So what is recommended is that routinely people go every three months to have their diabetes checked out. And this really needs to be a visit that is not an acute visit for something else. This needs to be, you know, "Hey, how's my blood sugar? How's my blood pressure?" And I really recommend that people keep track of it because there are such clear targets and guidelines. You really need to know what was your blood pressure last month? What is it three months from now? And if it's not normal, you need to ask, "How can I get it better"? Because people who take a proactive approach to their diabetes do beautifully.
When should I get emergency care if I have diabetes?
A really serious problem that people with diabetes have is that they end up getting amputations of their feet and legs. In fact it's the #1 reason for amputations in the United States, separate, of course, from motor vehicle accidents. It turns out the most reasons people need amputations is because they get a little tiny cut or sore in their foot and they have what we call "diabetic neuropathy" which means they can't feel that. Not everybody with diabetes has neuropathy, but those who have nerve damage can't feel that little cut or sore and then it will spread and it can get bigger and bigger and then go to the bone and then they'll end up losing their foot. However, if people with diabetes check their feet every day and call the doctor if they see anything abnormal, they can prevent anything bad from happening. There are many other reasons that people with diabetes can go to the hospital or the emergency room. Sometimes it's because they run out of their medication. Sometimes it's because they didn't give enough insulin because they were infected and their blood sugars went up real high. If someone with diabetes on insulin is vomiting and can't keep down food, they don't have any sugar to feed the insulin with and they have to go to the hospital. Low blood sugar reactions can also require someone to go to the hospital. A low blood sugar reaction means that the blood sugar has fallen so low that a person can fall into a coma. Now, the good news about that is that if people with diabetes check their blood sugar levels at home, they can often prevent severe low blood sugar reactions, and there's also a shot called "glucagon" that people can have at home and that a family member could give them to just wake them up. The final thing about low blood sugar reactions is that everybody with diabetes on insulin should have a medical alert that they wear on their body somewhere so that if some bad reaction happens and you're out on the street, people will know why you're having that reaction. So, there are a whole host of things that can happen with diabetes, but the vast majority can be prevented if people know how to prepare for them and then what to do, and finally if they have access to health care when there's an early warning that something's going on.
How are blood sugar levels tested?
What's really nice about diabetes is that you can watch over your disease yourself at home. And we have these blood glucose monitoring devices now, which there are probably, I don't know, 2, 3, 5, lots and lots of different meters. It doesn't matter necessarily so much which one you have, but you need to have one that you understand how to use: A), and B): in many cases that your insurance pays for. But you want to be able to monitor your blood sugar so you know what your sugar level is. And so these machines require that you poke your finger with a lancing device, and the lancing device you just - it's like a little pin prick. And I might add this is actually slightly more painful than giving insulin shots. This is part of diabetes that a lot of people don't like, but it gives very useful information. But you poke your finger and then there's a machine that has a little strip in it. You touch that strip to the drop of blood, and within a few seconds it tells you what your blood sugar level is. And I find these invaluable in terms of blood sugar testing. Now the problem with this is that, say you test your blood sugar four times a day before each time you eat, so you can figure out how much insulin to give, or maybe after you eat, so you can figure out what your blood sugar did in response to a meal. That still leaves lots of time when you have no idea what your blood sugar is, and it can be going up and down or whatever in between. So we now have ways to monitor blood sugar levels continuously by little devices that you attach on to your skin that talk to a device like a pager and tell you what your blood sugar is all the time. And those devices are just new, but they're really fascinating and really helpful in managing people who take insulin injections.
What is a "glycosylated hemoglobin" or "hemoglobin A1c" test?
A "glycosylated hemoglobin" level or “hemoglobin A1c” is a test that measures your average blood sugar for the past 3 months. And it's incredibly helpful because in any given day, someone with diabetes has a blood sugar that goes up and down and up and down again, and what you want to know is really the average blood sugar for the past 3 months. I know that if your hemoglobin A1c is less than 7, your risk of complications, of going blind or going on dialysis is much less. Now all of us have glucose in our blood, so all of us have a hemoglobin A1c level that is somewhere between 4 to 6. So 4 to 6 is normal. But more and more glucose will attach on to your cells as your glucose level goes higher, so the hemoglobin A1c, which is how much glucose is attached to your red blood cells, increases as the average level of sugar in your blood increases. It's a very important test to have checked every 3 to 6 months: every 3 months if you're on insulin, every 6 months if you're on pills, and your blood sugars are pretty stable. But you need to know that number and really be invested in that number. My patients cheer and celebrate when their A1c levels get down below 7 and are really where they want them. That's a great number to know and really vital to managing diabetes.
How often should the hemoglobin A1c test be performed?
The haemoglobin A1c test is a test of the average blood sugar level over about 3 months, and that 3 months is actually the life span of a red blood cell. That's how long we're testing. It's basically how much glucose is attached to red blood cells. So, if you're on insulin, or your diabetes is changing, we recommend that you have a haemoglobin A1c test every 3 months. If someone is on pills and their diabetes is really stable, then they probably should only do the haemoglobin A1c test every 6 months. However, I really recommend every 3 months for most people with diabetes to have a haemoglobin A1c test. A lot of us, if we say we are going to do something every 3 months, end up doing it every 6 months anyway. So, I think it's a very important number and one that people really need to be aware of and follow closely in monitoring their diabetes.
How often should I have my eyes checked if I have diabetes?
People with diabetes can get what's called "diabetic retinopathy" which is damage to the back of the eyes due to high blood sugar levels. Diabetic retinopathy is the leading cause of blindness in adults in the United States, so it's a very serious problem. A lot of my patients say to me, "Why do I need to get my eyes checked, my vision is fine?" The point is that your vision is not necessarily different and yet your eyes can be damaged and damaged and damaged and you won't know it until you go blind, or you bleed into the back of your eyes, or something horrible happens. So, everybody with diabetes should go every year to the eye doctor and get a dilated eye exam, which means they put drops in your eyes to make your pupils dilate and they then look in the back of your eyes very carefully to make sure there's nothing there. There are some people who are under very good control. Their haemoglobin A1C or average blood sugar test is in the normal range and if they don't have any changes in the back of their eye the eye doctor may say come back in two years. However, as a rule of thumb, I say go every year just to be sure that there's nothing there, because if there is something there they can treat it with laser therapy and things are fine.
Why should I should I have my urine checked if I have diabetes?
Diabetes is the leading cause of kidney failure in the United States, but it's a preventable problem, like most of the problems associated with diabetes. And one of the important things about preventing diabetic kidney damage is knowing that there's any damage. And so there's a very early test called a urine albumin creatinine ratio, it's a very little early test to tell us if there's any leakage of protein at all from the kidneys caused by diabetic kidney damage. It tells us if there's even early damage caused by the diabetes. And if there's early damage caused by the diabetes, we can give certain medications to help prevent that early damage from progressing to kidney failure. So every year, people with diabetes, whether type 1 or type 2, need to get a urine test. It's not a 24-hour urine, it's just a urine sample. And you need to ask the doctor to test for diabetic kidney damage. So it's a slightly special test that's not the routine test done on someone without diabetes, and it's one that many doctors don't do. But it's very important to do yearly to be sure that diabetic kidney damage isn't happening, because we have treatments to help if it develops.
Why should I have the sensation in my feet checked if I have diabetes?
People with diabetes get what's called peripheral neuropathy, which means that they lose sensation in their feet and toes. The reason this is important is because diabetes is the leading cause of non-traumatic amputations in the United States. What happens is that your feet might not feel that you've got a cut or a sore. I've had people come to see me with tacks in their feet because they didn't feel the thumbtacks, because they have no sensation. So, every year your doctor needs to check your feet, and tell you if you do have normal feet. If you have diabetes and you have normal sensations, then you're probably pretty similar to anybody else with normal feet. However, if your doctor checks and you have any damage to your feet, if you have poor circulation in your feet, if you have a loss of sensation, if you have foot deformities: bunions, hammer toes; all of those things can make the feet not quite normal. If you have any abnormality in your feet, then you should be absolutely certain not only to have your doctor check your feet every single time you go to see your health care provider, at least three times, four times a year, but also every single day your should check your feet yourself to see if there are any cuts, sores, or lesions, and then if there are, you need to call your doctor right away.
How often should I be screened for heart disease if I have diabetes?
People with diabetes have many risk factors for heart disease. The major risk factors are high blood pressure and abnormal cholesterol levels. Those abnormal cholesterol levels include in particular a low level of HDL, or "good" cholesterol, and a high triglyceride level. We recommend that people with diabetes have their blood pressure checked every time they come see the doctor, and that really the blood pressure is very well controlled. If someone has heart disesase we probably check their cholesterol level two to three times a year. If someone doesn't have heart disease and has normal cholesterol levels we check their cholesterol levels once a year.We tend to be very aggressive at treating both blood pressure and cholesterol levels in people with diabetes because their risk for heart atack and stroke is so high.
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