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- Home - | - Episode 54: Diabetes and MASLDIn Episode 54, Dr. Sarkar welcomes Dr. Jamie Hamilton, who will be talking with us about diabetes and metabolic dysfunction associated stenotic liver disease or MASLD. Dr. Hamilton is an associate professor of medicine in the division of gastroenterology and hepatology. He is the interim director of gastroenterology and hepatology and the director of hepatology for Johns Hopkins Medicine. Dr. Hamilton’s clinical specialties include Wilson’s Disease, cystic fibrosis related liver disease, liver transplantation, hepatocellular carcinoma, cirrhosis. Portal hypertension, acute and chronic viral non-alcoholic fatty liver disease, autoimmune,and cholestatic liver disease. Dr. Hamilton is a recipient of the National Institutes of Health National Research Scholar Award for gastroenterology and hepatology.
Download TranscriptTranscript: Episode 54: Diabetes and MASLDSudipah Sarkar: [00:00:00] Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Sudi Sarkar at Johns Hopkins. we developed this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkins diabetes info.org.
Today we’re excited to welcome Dr. Jamie Hamilton, who will be talking with us about diabetes and metabolic dysfunction associated stenotic liver disease or MASLD. Dr. Hamilton is an associate professor of medicine in the division of gastroenterology and hepatology. He is the interim director of gastroenterology and hepatology and the director of hepatology for Johns Hopkins Medicine.
Dr. Hamilton’s clinical specialties include Wilson’s Disease, cystic fibrosis related liver disease, liver transplantation, hepatocellular carcinoma, cirrhosis. Portal hypertension, acute and chronic viral non-alcoholic fatty liver disease, autoimmune, [00:01:00] and cholestatic liver disease. His research interests include copper homeostasis and its regulation of lipid metabolism and liver injury, fundamental mechanisms regulating liver fibrosis and the molecular genetics of hepatocellular carcinoma in early detection Biomarkers.
Dr. Hamilton is a recipient of the National Institutes of Health National Research Scholar Award for gastroenterology and hepatology. Welcome, Dr. Hamilton.
Jamie Hamilton: Thank you Dr. Sarkar.
Sudipah Sarkar: One question that we wanted to start off with today is, what exactly is metabolic dysfunction associated ketotic liver disease or MASLD? And could you tell us a little bit about what the name used to be and how did that shift and how does it better reflect how we understand the disease?
Jamie Hamilton: The disease used to be called “non-alcoholic fatty liver disease”. That was considered not to be a great name because it was a diagnosis of exclusion and many people didn’t really pay attention to the diagnosis because they just said the liver enzymes are mildly elevated [00:02:00] and it’s not that big of a deal. The reason for the name change was to really understand who was at risk for this disease, then make a diagnosis of the disease, and then who is at risk for developing serious liver problems from the disease? So there are five criteria, metabolic criteria that we use to determine who is at risk for the disease. And that’s having a obesity or overweight, so A BMI in Caucasians of over 25, and then E East Asians of over 23.
Or an an increased waist circumference of over 90 centimeters in men or 80 in women. Having a high triglyceride count over 150, having a low HDL less than 40, or on medicines to control lipids having high blood pressure or on medicines to control blood pressure or having most importantly type two diabetes and insulin resistance.
So people who have those problems are at risk for having fat in their liver. And we don’t like to use the word fatty liver ’cause fatty is not really a nice word. So we call it steatosis or st thetic liver. And that’s just a [00:03:00] doctor word for fat in the liver. There’s three main reasons why people get fat in the liver.
First one is alcohol. Second one are these metabolic problems. And then the third one. Is much more uncommon. It can be genetically caused or from medicines. But the main reason was take away the stigma of the word “fatty.” Take away the word “non-alcoholic” and really be more inclusive by saying, these are these in really important metabolic problems. Those people with those metabolic problems are at risk for having fat in their liver.
Sudipah Sarkar: Thank you. That’s very helpful. This is a podcast about diabetes and I know a lot of our listeners will be asking which comes first, is it that someone has diabetes and then they develop MASLD? Or do people usually have MASLD and then develop diabetes?
Jamie Hamilton: Usually they develop concomitantly or at the same time, usually at the time of a diagnosis of type two diabetes, the person, a patient will have some fat in their liver. It’s not as though it’s pretty, it would be pretty uncommon for someone to have fatty liver [00:04:00] first or steato liver first and then be diagnosed with diabetes later. But it is possible.
But they’re very tightly linked because. People who have type two diabetes have resistance to the insulin that they’re making, as and among other hormone problems they get. With this insulin resistance, you end up storing fat. In the liver inappropriately, and that’s what leads to the fatty liver.
And you mobilize fat from the your adipose tissues that goes to the liver. And then your liver continues to make its own fat and not checking that you or stopping that in the presence of having fat in the liver, but it can continues to make its own fat. And then of course you get fat from the diet.
Sudipah Sarkar: Another question that many listeners might have is how do you detect maced or how can a patient or their provider find out if they have MASLD?
Jamie Hamilton: The first thing obviously is just a routine checkup with either your diabetes specialist or primary care physician in which liver enzymes can be checked.
And they could be elevated, but that really shouldn’t be the [00:05:00] only test that are is done. There’re an ultrasound of the liver, which is a very non-invasive, easy test to be done should be done to measure fat in the liver. And so what is recommended now is someone who has these risk factors should be screened for fat in the liver, with liver enzymes and with an ultrasound.
And then there’s another simple test that you can use with existing blood tests. It’s called A Fib four, and it stands for Fibrosis four. And the four labs that we use or values that we use are the A ST, the A LT, which are liver enzymes, the platelet count, which is part of the complete blood count, and then the patient’s age.
And you put those numbers into a formula and it can put out a number. If that number is greater than 1.3, then the person could potentially have scar tissue in the liver. And if it’s greater than 2.6, the person, the patient likely has scar tissue in the liver and that should prompt further investigation as well.
So looking for fibrosis is really the most important thing in these [00:06:00] when you make these diagnoses, because that’s what really leads to liver damage is fibrosis in the liver.
Sudipah Sarkar: Based on the FIB four score, what further imaging tests could a general practitioner or endocrinologist order especially if it if it’s exceeds one of the cutoffs.
Jamie Hamilton: So what we generally recommend is something, there’s a thing called a FibroScan, which is an another non-invasive test. It requires a patient fasts for four hours prior to the exam, and then they put a probe on the abdomen over the liver and it measures the amount of fat in the liver and it measures the stiffness of the liver.
And from that, we can determine if there is scar tissue or not. There’s no IV needed. There’s no dye, there’s no biopsy needed in that situation. It’s it’s pretty non-invasive. There’s also a blood test called ELF or Elevated liver fibrosis, which is available at most commercial laboratories.
And that’s a really good blood test too, that can be used to estimate fibrosis. We don’t generally recommend something called the Nash fibro [00:07:00] brochure. That test is is pretty unreliable. And we don’t recommend that.
Sudipah Sarkar: At what point would you say that a patient should be referred to a liver specialist,
Jamie Hamilton: Anybody who has suspected fat in their liver and fibrosis.
Now, of course, if the problem is this is. This liver disease is the most common in the world, and about 30% of Americans probably have fat in their liver. So we can’t see all of them. So we do try and limit our evaluations to those who are just suspected to have fibrosis. One thing I will say too is patients that fib four test is not very reliable.
Once a patient gets over 65 or so. Then it starts to overestimate fibrosis. And so that can be more tricky. And in those patients you might want to go directly to a FibroScan to assess for fibrosis.
Sudipah Sarkar: In terms of treatment, what are treatments that are recommended to treat MASLD ?
Jamie Hamilton: The first thing we always recommend is trying to improve your metabolic risk factors and that we do that through dieting and exercise [00:08:00] because we know that weight loss can improve this condition markedly.
So we recommend generally what’s called a Mediterranean style diet, which is of course, rich in fruits and vegetables and lean proteins such as fish and chicken, and avoiding things like high carbohydrate diets, high fat containing diets, fatty meats like steak, And really portion control as many of your diabetic patients are aware of.
We also ask people to really reduce or avoid alcohol entirely because there really is no amount of alcohol that is safe for the liver. And then we also recommend routine exercise. Trying to exercise 30 minutes, five days a week, 30 days, 30 minutes a day, five days a week. Is ideal. If you do more than that’s even better.
And we studies have shown that if patients engage in that type of activity and are able to lose weight they do improve their metabolic risk factors and then they approve their fatty liver. But when someone has fibrosis, it’s a little bit more serious. And so in that case, there is one medicine that is [00:09:00] approved for this condition and it’s called Remeron.
And it was approved in March of 2024. And and it’s only approved in patients who have fat in their liver and stage two to three fibrosis. And so we determine that through a FibroScan. You can also do a liver biopsy In general, I don’t do liver biopsies for this condition too much unless there’s a competing diagnosis. And there’s also something called an MRI Elastography, which can also measure liver fibrosis, but of course that’s a more expensive test. But this drug rasmaderon. It was shown after a one the clinical trial was about one year long, and they enrolled patients many of whom had diabetes but all of whom had.
Fat in their liver in stage two to three fibrosis, and about 30% of patients at the end of that first year had a full one stage reduction or more in their liver fibrosis and in resolution of their steato hepatitis or their fatty liver. That is what we do for patients who have fibrosis.
I will say that really any strategy to reduce weight improves fatty liver. So many of the drugs that are used now [00:10:00] in diabetes also have the benefit of weight loss. So drugs like Mounjaro or ozempic or other types of what we call GLP one analogs they tend to help people lose weight and their fatty liver often improves.
And there been recently some clinical trials showing. Real benefit in patients with fatty liver disease and fibrosis in particular manjaro. Tirzepatide. It was published in the New England Journal of Medicine, a phase three trial showing about 50% of patients had a one or more stage reduction in their scar tissue.
So that’s an emerging indication for this condition, this fatty liver disease. But it’s not yet FDA approved it’s not a standalone drug just for this condition. Some people who have very significant obesity will also benefit from bariatric procedures. And in those patients, their metabolic risk factors rapidly improve after weight loss from those conditions.
So that’s always something to consider too. So things like endoscopic sleeve gastrectomy or surgical sleeve gastrectomy or gastric bypass can be of use.
Sudipah Sarkar: [00:11:00] Are there any exciting avenues of research and innovation that you could share with us in the field of MASLD and metabolic disease?
Jamie Hamilton: I think that the pharmaceutical industry is extraordinarily excited about this condition just because it really affects a third of the world’s population. So there’s something like 75 clinical trials that are ongoing right now at various different stages of development. And and all of these have very exciting preclinical data and e even some small, clinical trials showing benefit.
That’s really the major area of research is actually getting to the patient soon. Is are all these different meds that affect the way the liver handles fat and reduces inflammation and reduces fibrosis.
Sudipah Sarkar: In your experience, what would a coordinated care model look like for someone who has both MA and diabetes?
Jamie Hamilton: So I think a nice coordinated care model would be a team, a team that includes a liver specialist, an endocrine diabetes specialist and perhaps someone who specializes in medical weight loss [00:12:00] therapies. And sometimes in some cases, patient someone that specializes in lipid control lipid medicine sorry, lipid lowering therapies.
And sometimes that can be just a really good primary care doctor. And sometimes some cases it can be a specialist. But those are usually the general people that would be involved.
Sudipah Sarkar: Are there any over the counter medications that are used for treatment of MASLD?
Jamie Hamilton: I would not necessarily recommend over the counter supplements for the treatment of this condition. There are a lot of nutraceuticals or remedies that are out there in the lay media and in and in your health store that have been. Touted to help fatty liver disease. None of those have really been rigorously studied and have shown no benefits that we know of.
So I would be really cautious about using any of those. And many herbal preparations or holistic therapies can actually be liver toxic. So I would caution people against using those without the advice of a healthcare professional.
Sudipah Sarkar: Dr. Hamilton, are there any symptoms that a patient with diabetes [00:13:00] might see if they have MASLD.
Jamie Hamilton: That’s a really good question. So unfortunately, when maed in its early stages, it’s really asymptomatic.
You may have mild elevations of the liver enzymes. You may have some abdominal pain in the right side, that’s just vague and hard to describe. But in general, it doesn’t really cause a lot of symptoms. Unfortunately, by the time that. Liver disease really progresses towards cirrhosis.
You can have symptoms and that can be fatigue. It can be yellowing of the skin, it can be swelling of the legs. You can have bleeding problems, you can have confusion, but we really want to find people and treat people well before that happens.
So the answer to the question in the beginning stages, there’s really no symptoms. But as the disease progresses, it can have a lot of different symptoms and much of which can be vague. But fatigue, itching, yellowing of the skin would be really big things of concern.
Sudipah Sarkar: What complications is associated with both liver complications and heart complications.
Jamie Hamilton: [00:14:00] So the the most important liver complication is, is cirrhosis which is a scarring of the liver that can lead to liver failure and it can lead to liver cancer. So MASLD d is the second leading cause of liver transplantation in United States and North and and Western Europe. Oh. And it’s a fire alarm. The and then the heart complications of people with MASL D or fatty liver disease are things like coronary artery disease and heart attacks and arrhythmias and heart failure, all related to the same risk factors that cause the liver disease often cause heart disease as well.
Sudipah Sarkar: What resources do you recommend to your patients for more education about MASLD?
Jamie Hamilton: We try and give a lot of education in our clinics, but we also refer patients to the Hopkins website for information about the Mediterranean diet, for example. That, that is really the main resource we use. And we give out in our after visit summaries, we give out information on diet plans and exercise plans.
Sudipah Sarkar: Dr. Hamilton, thanks so much for your time. It’s been great talking with you and thanks for sharing your recommendations and experience.
Jamie Hamilton: Great. [00:15:00] Thank you so much.
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- Home - | - Episode 53: Diabetes and Cardiovascular Disease in WomenIn Episode 53, Dr. Sarkar welcomes Dr. Erin Michos, MD, MPH, who will speak with us about diabetes and preventive cardiology in women. Dr. Michos is a professor of medicine within the division of cardiology at Johns Hopkins School of Medicine with joint appointments in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. She’s the director of Women’s Cardiovascular Health and the Associate Director of Preventive Cardiology within the Johns Hopkins Chicharone Center for the Prevention of Cardiovascular Disease. Dr. Michos is an internationally known expert in preventive cardiology in women’s health. Her research involves women’s cardiovascular health, lipids and lipid management, cardio, kidney metabolic, and obesity, disease management, coronary artery, calcium, inflammation, and biomarkers of cardiovascular risk. She was the recipient of the Nanette Wegner Award for Women’s Health Medical Leadership by the Women Heart Organization and the Donna Vogel Women’s Health Champion Award by Johns Hopkins University.
Download TranscriptTranscript: Episode 53: Diabetes and Cardiovascular Disease in WomenSudipa Sarkar: [00:00:00] Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Sudi Sarkar at Johns Hopkins. We develop this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkins diabetes info.org.
Today we are excited to welcome Dr. Erin Mikos, who will speak with us about diabetes and preventive cardiology in women. Dr. Mikos is a professor of medicine within the division of cardiology at Johns Hopkins School of Medicine with joint appointments in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health.
She’s the director of Women’s Cardiovascular Health and the Associate Director of Preventive Cardiology within the Johns Hopkins Chicharone Center for the Prevention of Cardiovascular Disease. Dr. MicMikos is an internationally known expert in preventive cardiology in women’s health. Her research involves women’s [00:01:00] cardiovascular health, lipids and lipid management, cardio, kidney metabolic, and obesity, disease management, coronary artery, calcium, inflammation, and biomarkers of cardiovascular risk. She was the recipient of the Nanette Wegner Award for Women’s Health Medical Leadership by the Women Heart Organization and the Donna Vogel Women’s Health Champion Award by Johns Hopkins University. Welcome, Dr. Erin Mikos.
Erin Mikos: Thank you for having me be part of your program.
Sudipah Sarkar: I wanted to start off with asking you a general question. When we think of preventive cardiology for people with diabetes. What does this look like?
Erin Mikos: Unfortunately, cardiovascular disease, which includes both heart disease and stroke and peripheral artery disease, this still remains the leading cause of death in individuals with diabetes, both men and women.
And this is why attention to prevention and treatment of cardiovascular risk factors is just so [00:02:00] important. While in patients who do not have diabetes. There’s what we call a female advantage, where sometimes women get heart disease about 10 years after men do, but in the setting of diabetes, they, we don’t see this.
There is no female advantage and women with diabetes get this. Same earlier onset of cardiovascular disease as men do. If we don’t institute preventive therapies and while men have a greater prevalence of diabetes , in the setting of diabetes confers a greater relative risk of cardiovascular disease of heart attacks and strokes in women relative to men. So the impact of diabetes impacts women more than their male counterparts.
Sudipah Sarkar: That’s very helpful to know. In terms of cardiovascular outcomes that we see in people with diabetes could you highlight some outcomes that are different between men and women?
Erin Mikos: Yeah. So [00:03:00] as I mentioned, diabetes confers a greater relative risk of heart disease and cardiovascular disease and women compared to men. Women with diabetes can still get their traditional cardiovascular disease, the obstructive coronary disease that we see that can lead to needing stents or bypass.
But women are more likely than men to also get ischemia or cardiovascular disease without obstruction in their heart, arteries from microvascular dysfunction so they can have symptoms of angina, chest pain of their heart, indicating their heart’s not getting enough blood flow where there’s not a problem in the large arteries.
But there’s a problem in the small arteries. That is a more common phenotype in women than in men. But, cardiovascular disease still impacts women and unfortunately, despite the fact that this is the leading cause of death in women, in all women and women with diabetes, we know that women continually [00:04:00] get less treatments compared to their male counterparts.
For example, women with diabetes are less likely to be treated with a statin medication. Even though this is a class one indication, the strongest recommendation that everybody over the age of 40 with diabetes should be treated with a statin. Women are less likely to get this important preventive therapy.
Women with diabetes are less likely to have their blood pressure controlled. They’re less likely to have their LDL cholesterol control to their marital counterparts, and they’re less likely to be treated, with other preventive medicines. So there’s a lot of disparities, which may be why women have worse outcomes in the setting of diabetes as their male counterparts.
Sudipah Sarkar: Do we understand why there are differences in prescribing practices for men and women with diabetes when it comes to medications that can help prevent cardiovascular disease?
Erin Mikos: I think unfortunately there’s still a bias, a misperception that cardiovascular disease is a male disease, even though it’s [00:05:00] the leading health threat in women.
And this’s this presumption that women are lower risk. But as I just mentioned, there is no female advantage in the setting of diabetes. Women have just as equal risk as men do, so they’re presumed to be at lower risk. Both patients themselves female patients often don’t see, think of themselves as being at risk for heart disease.
But also clinicians unfortunately tend to undertreat women and some of the risk calculators may. Low ball women because some of the risk calculators we have for cardiovascular disease don’t include, female specific factors of such as gestational diabetes and preeclampsia and early menopause and polycystic ovary syndrome, which are all, these female specific risk factors, which not only increase the risk for diabetes, but they increase the risk for cardiovascular disease.
So women are underestimated in risk unfortunately, and this can lead to undertreatment.
Sudipah Sarkar: Could you tell [00:06:00] us a little bit more about these specific risk factors in women and how these risk factors impact the future risk of cardiovascular disease such as gestational diabetes in polycystic ovarian syndrome?
Erin Mikos: Traditional risk factors do confer a greater risk in women compared to men. Hypertension, diabetes, smoking, they’re bad for both men and women, but they confer a greater risk in women compared to men. And at the time of diabetes diagnosis, women tend to have higher body mass index and more cardiovascular risk factors at the time of diagnosis.
So that may be. Partly why they’re increased risk. But in addition, there are unique risk factors specific to women that increase their risk of both diabetes and cardiovascular disease throughout their lifetime that men do not experience. Specifically polycystic ovaries syndrome. This is the most common endocrine abnormality in women of reproductive [00:07:00] age. About 10% of women have PCOS. And although elevated body mass index is a feature, many women with PCOS, even lean women who have PCOS are more likely to have insulin resistance. So insulin resistance kind of underpins PCOS because there are more androgens, more male like hormones being made by the ovaries.
So we know that women with PCOS have a threefold increased risk of developing type two diabetes. And they’re also at increased risk of cardiovascular disease. Another major risk factor that’s female specific is having an adverse pregnancy outcome such as gestational diabetes or a history of preeclampsia, preterm delivery.
And the risk doesn’t end at delivery. This risk extends even, decades after their index pregnancy, which is why clinicians need to ask women about their reproductive history of ask about their pregnancies. Even if the women are years out of their childbearing years, this risk continues.
So we know that gestational [00:08:00] diabetes is a huge risk factor for developing type two diabetes. There’s about a tenfold risk that women with gestational diabetes will ultimately go on to have type two diabetes. They also have about a twofold risk of developing cardiovascular disease because. Pregnancy is like nature’s free stress test.
And so if this insulin resistance is unmasked during pregnancy, they’re often likely to get, develop diabetes, later in life, which is why after pregnancy with gestational diabetes, women need their A one Cs checked regularly, at least annually. Now we also know that early menopause is a risk factor for cardiovascular disease, and some studies suggest it’s a risk factor for diabetes too.
So we call menopause before the age of 45 is early and before the age of 40 as premature. And that is the loss of early estradiol is a risk factor for developing cardiovascular disease. But some studies suggest that early menopause may be a risk factor for diabetes. That in a [00:09:00] study called the Rotterdam study, women who had menopause between ages 40 to 45 were twofold, more likely developed Type two diabetes, and women with menopause before the age of 40 we’re threefold, more likely.
We also saw this in the Women’s Health Initiative, observational study. If you look at reproductive years between menarchy, the onset of menses and menopause women with short reproductive periods less than 30 years were 37% more likely to develop type two diabetes. And then also vasomotor symptoms is important flag that may highlight women that have increased sympathetic activity insulin resistance, hot flashes are not benign. Vasomotor symptoms, which are those hot flashes and night sweats are experienced by 75% of women transitioning through menopause. But women who have very severe vasomotor symptoms or persistent vasomotor symptoms that are lasting beyond five years, that’s a [00:10:00] hallmark of increased cardiovascular risk.
We know that in the Women’s Health Initiative, women with severe vasomotor symptoms were 48% more likely to develop type two diabetes. Those are all risk factors for diabetes as well as cardiovascular disease.
Sudipah Sarkar: Wow. Dr. Mikos, you mentioned for clinicians, we use risk calculators to help patients and ourselves under better understand a patient’s cardiovascular risk in the future.
Are there risk calculators that are. Built for women with diabetes, and if not would you suggest that more clinicians incorporate risk factors that are unique to women when they’re having that discussion about cardiovascular disease risk? For the individual patient?
Erin Mikos: Yeah, so in individuals who already have cardiovascular disease, we call that secondary prevention.
And they already had an event, like a heart attack or stroke, so they need very intensive treatment. We have very low LDL cholesterol targets. [00:11:00] So these risk calculators are meant to be applied to people who are ages 30 to 79 who, are not known to have cardiovascular disease. It’s a starting framework and the one that we’re currently using is something called the prevent score that came out from the American Heart Association.
It does include diabetes in that calculator. But I will note that we’re not doing in persons with diabetes, we don’t use that calculator to determine statin indication. If someone’s over the age of. 40 they’re indicated for a statin regardless of whatever that tenure calculator says. And if they have diabetes and another, major risk factor, we’re aiming for an LDL target less than 70 milligrams for deciliter in persons with diabetes, even if they haven’t had a prior heart attack.
So this tenure risk calculator, which can be used in persons with or without diabetes, is a starting framework and includes some basic things like diabetes. Smoking age, their, sex with their male or female their blood pressure. Some basic [00:12:00] lipids, whether they take medications for their lipids or their blood pressure.
But there are lots of things that we know increase risk that are not in that calculator. We call these risk enhancing factors like having these female specific factors of preeclampsia early menopause. Autoimmune disease like rheumatoid arthritis and lupus which are more prevalent in women.
This substantially increases cardiovascular risk because of inflammatory condition. There’s things like chronic kidney disease, having a family history of premature coronary disease metabolic syndrome and biomarkers like having an elevated lipoprotein little A or a OB having levels of inflammation with a high sensitivities.
CRP test that’s elevated. If any of these are present, we call them risk enhancers and they put individuals into a higher risk category than they might have been by the tenure calculator. But I will mention again, that just having diabetes already put someone into a much higher [00:13:00] risk where we’re being very intensive about primary prevention.
Sudipah Sarkar: This is a great, this is very helpful, Dr. Mikos. Can you tell us about what key prevention strategies might look like in women with diabetes who are motivated to decrease their risk of cardiovascular disease in the future?
Erin Mikos: Yes. Blood pressure control is important for everybody but persons with diabetes, we start anti-hypertensive therapy if the blood pressure’s above one 30 over 80.
And we try to target under that goal once we start treatment. Although lowers little even better. A normal blood pressure is less than 120 over 80, so they need blood pressure control. And if a person with diabetes, we wanna check to see if they have any, protein in their urine. We know that urine micro albuminuria is a major important risk marker, not only of risk of kidney disease, which diabetes is a leading cause of kidney disease, but also it’s a risk factor for cardiovascular disease.
If there’s any blood pressure elevation in this setting of having [00:14:00] protein in the urine. There’s a class of medicines ACE inhibitors or ARBs that we would use. So that’s blood pressure. Lipids, as I mentioned, you have diabetes, should be on a statin. And we have lower targets in someone who has diabetes plus other risk factors. We wanna get the LDL under 70. If someone’s had a prior heart attack, that’s a whole different story. We want the LDL even lower, less than 55. And we have a number of medicines, statins, but we have non-statin medicines. Statins are not the only game in town. We have a lot of medicines to treat lipids these days. We gotta treat lipids.
Of course, glucose control is important. Now there are some, a new I guess they’re not new anymore. They’ve been using them since 2016, but there are some class of medications used to treat diabetes that are actually cardiovascular prevention medicines that reduce the risk of cardiovascular disease.
And these are the GLP one receptor agonists and the SGL two inhibitor medications. So I’ve been prescribing these as a cardiologist since [00:15:00] 2016 when we had some pivotal trials called the leader trial and the sustained six trial looking at GLP one receptor agonists. And then the the EMPA reg trial looking at empagliflozin, which is an SGL two inhibitor. These medicines substantially reduce the risk of having cardiovascular events in patients with diabetes that were high cardiovascular risks. So these are prevention medications. So the guidelines have endorsed that persons with diabetes who are at elevated cardiovascular risks that have, several of these major cardiovascular risk factors or established cardiovascular disease, you really wanna prioritize medications that have organ protection that prevent heart attack and strokes and heart failure and kidney disease. And so you wanna prioritize these medications that have these cardio kidney benefits over some of the older medicines , like sulfonylurea. We wanna really prioritize those medications. Now the good news is that in these trials that I mentioned.
When they look at effects by sex [00:16:00] that women benefited just as much as men do with these therapies in terms of cardiovascular risk reduction and kidney disease risk reduction. When treated women benefit as much as men do.
In fact, some real world data that we have, outside of trials, looking at real world data from market scan showed that women with diabetes treated with this class of medicines called GLP one receptor agonists, they actually had even greater benefit from this class of medicines than men do.
So they benefit from therapy. We just need to make sure that we treat them. But unfortunately, we still have gaps where in clinical trials, which is where we figure out how, medicines are safe, do they work? Do they benefit patients? Clinical trials, shape guidelines. But we know that women continually are under es under -enrolled, underrepresented in clinical trials.
For lipid-lowering therapies and new diabetes drugs, et cetera, compared to their male counterparts. So we [00:17:00] need to make sure we have equity of representation in trials that we know that these, new drugs are safe and effective in both men and women.
I could say the foundation for all preventive efforts is lifestyle, interventions. So generally the Mediterranean diet is one we recommend for patients.
There is evidence for cardiovascular benefit with the Mediterranean diet. So the diets that have beneficial for cardiovascular risk or diets low in saturated fat low in trans fats, but can have a modern intake of the healthier fats. The monounsaturated polyunsaturated fats that we see in fish like salmon, nuts olive oil, avocado want diets, rich in fruits and vegetables whole grains can lower LDL and we want to minimize processed foods as much as possible and try to minimize or limit, sugar sweetened beverages which can increase the risk of cardiovascular disease as well as type two [00:18:00] diabetes. We encourage physical activity. Individuals should get at least 30 minutes of moderate intensity activity most days of the week, at least five days a week, or 150 minutes a moderate activity per week.
Now, it doesn’t have to be vigorous someone’s trying to get more fit. Vigorous exercise may help with fitness, but in terms of cardiovascular benefit, we see most cardiovascular benefit at the moderate level. Brisk walking is a moderate intensity activity that most adults can do that as well as, more leisurely cycling, some easy jogging, a dance class, some moderate intensity gardening.
It doesn’t have to be vigorous, but we do want someone to do something active all day long and even light activity such as leisurely walking, has more benefit of over being sedentary. Getting those step counts in, we aim for. Trying to aim for 10,000 steps a day, but trying to go for at least 3000 more steps compared to where your baseline, where your starting is.
[00:19:00] So everybody benefits from exercise and lifestyle changes, both men and women. And interestingly although women are unfortunately are less active than men, when you look at physical activity. The cardiovascular risk reduction that we see the decreased risk that of heart disease we see with physical activity actually occurs at lower thresholds in women compared to men.
Women start getting heart benefit, cardiovascular benefit at lower amounts of exercise compared to their male counterparts. So if we can just get women patients moving more that, that can have significant benefit. But when you talk about diabetes, because the diabetes already places them at higher risk, they will need some often preventive medications such as statins, on top of lifestyle changes. Because if they’ve already developed diabetes, they’re now in a higher risk category. But it’s not in either or. It’s a both. We need lifestyle changes and preventive pharmacotherapies to decrease their risk.
Sudipah Sarkar: Awesome. Super. That’s really helpful
you mentioned early [00:20:00] menopause as a risk factor for cardiovascular disease. Could you talk to us a little bit about the role of hormone replacement therapy and cardiovascular disease risk?
Erin Mikos: Probably, age related midlife increases in adiposity and insulin resistance have the strongest relationship with diabetes from chronological aging, where hormonal changes that characterize menopause or perhaps not the strongest determinants of a diabetes risk.
But we do know that the menopause transition, there’s this very unfortunate change in body composition that women experience where there’s more adipose or fat deposition in the abdomen, the visceral cavity. So even if a woman’s weight doesn’t change on the scale, there’s a shifting of weight in unhealthy places in the abdomen, which increases the risk of insulin resistance.
Now I mentioned early menopause is a marker of increased risk of diabetes. But we’re not using [00:21:00] hormone therapy for the sole purposes of primary or secondary prevention of cardiovascular disease or diabetes prevention. In trials like the Women’s Health Initiative, there was a signal that menopausal hormone therapy was associated with a decreased risk of incident diabetes and estrogen may have some benefit on glucose homeostasis glucose metabolism, such as improving one’s sensitivity to insulin or insulin secretion. But we’re not using it for this purpose. Hormones can’t have a double edged sword. We did also know, in the Women’s Health Initiative, there’s an increased risk in blood clots deep vein thrombosis and pulmonary emboli.
And in older women, increased risk of cardiovascular events and stroke. But hormone therapy did seem to be relatively safe in lower risk. Women who are, were closer to the menopause transition. So our, the current indication for hormone therapy is for the treatment of symptomatic vasomotor [00:22:00] symptoms.
Hot flashes or night sweats, so that’s the role for hormone therapy. It’s not for diabetes prevention or cardiovascular disease prevention. And we think it’s relatively safe for women who were under the age of 60 or within 10 years of menopause who are not at very high cardiovascular risk, such as, who haven’t had a heart attack or a stroke, or haven’t had a blood clot event, we think it’s relatively safe in those individuals.
The keeps trial which enrolled women closer to the menopause transition there was no evidence of cardiovascular or metabolic. Benefits or harm within four years of use of both oral or transdermal form of hormone therapy. So again, we’re not using hormones to prevent diabetes but it’s still a good option to treat vasomotor symptoms in our symptomatic, patients who are closer to the menopause transition
Sudipah Sarkar: Dr. MicMikos, could you outline for us what the terms primary prevention and secondary prevention mean?
Erin Mikos: Yes. So for [00:23:00] secondary prevention, these are the highest risk patients who’ve already had an event. They’ve had a heart attack, they’ve had a stroke before, or they’ve had revascularization, a bypass or stents in other arteries, such as in their peripheral arteries of their legs. And so this is the highest risk patients ’cause they have disease. And our goals are trying to prevent, a second event or a third event. So we call secondary prevention. So we have very intensive recommendations. We try to have very aggressive LDL targets less than 55 milligrams per deciliter. And these diabetes medicines, particularly the GLP one receptor agonists and the SGL two inhibitors are, really indicated for most of these patients because they’re so high risk and we know those therapies can reduce a subsequent cardiovascular event. Secondary prevention patients often are taking anti-platelet therapy such as aspirin, because they’ve already had an event. Now, primary prevention is people at [00:24:00] risk for a cardiovascular disease event and just having diabetes places someone at elevated risk of cardiovascular disease and we’re trying to prevent that first event. We call it primary prevention, and this is where we try to treat risk factors very intensively and because persons with diabetes are already at increased risk, we may treat them more intensively for, and even in the primary prevention setting than individuals without diabetes, just because having diabetes already puts them in a higher risk category.
We also have a third risk group that we call high risk primary prevention or primary prevention and a half, and this is individuals who have evidence of. Subclinical disease of atherosclerosis, a plaque in their arteries that we can see on imaging. They may have had a CT scan that have shown calcifications in their heart, their coronary arteries, or calcifications in their aorta, or maybe they’ve had a carotid ultrasound that shows plaque in their carotid.
So we know their arteries have disease in [00:25:00] them. Fortunately they haven’t had an event, but they have disease, we call it subclinical disease. They also get more intensive prevention because we know they have disease. And when if they have a significant burden of disease, such as a calcium score above 300, their risk of a heart attack is the same as someone who’s had a prior heart attack.
So we often treat them like a secondary prevention patient if they have a lot of plaque in their arteries and when there’s some. Certainty about risk. Sometimes we do order some of these tests such as a coronary calcium score to see, how much plaque they have in the arteries.
But keep in mind that calcified plaque is late stage plaque, so people can still be at risk even if they have a calcium score of zero because they can still have noncalcified plaque. So we still treat individuals with diabetes with a statin, regardless of their calcium score. So really it’s about risk stratification.
We wanna apply the most intensive treatment, the most intensive goals to the highest risk patients
Sudipah Sarkar: [00:26:00] are women susceptible at all to more adverse effects of medications that we use to help lower the risk of heart disease such as gLP one receptor agonists or medications for blood pressure or statins that you’re aware of?
Erin Mikos: In terms of the benefit, women benefit just as much. There’s no increased safety signal. Women benefit just as much from statins, GLP one receptor agonists, SGL two inhibitors in terms of the heart and kidney benefit. But we do know that women tend to report more side effects. For example, women treated with statin therapy, even though they get that same cardiovascular benefit, they tend to report more statin associated muscle symptoms, at least for lipid lowering therapy, we have other lipid lowering options that we can offer patients. So it’s really important that we still treat lipids but women can have more side effects. With GLP one receptor agonists, all patients can [00:27:00] experience some GI side effects. Actually, the good news is women sometimes lose more weight with GLP one receptor agonists than male counterparts.
Although persons with diabetes lose less weight with those agents than persons without diabetes, but we’re using them in diabetes. Actually not really for the weight loss indication, but for the cardiovascular prevention indication with SGL two inhibitors they have significant benefit in reducing risk of being hospitalized for heart failure.
They have significant benefit in reducing the risk of kidney disease. They have a small absolute risk, although a greater relative risk, but a small absolute risk of yeast infections. Not urinary tract infections, but genital yeast infections because sgl two inhibitors can cause you to have more sugar in your urine.
But the cardio and kidney benefits are so important and so great. That is not a reason to, not use SGL two inhibitors In patients with diabetes. Most yeast infections can be treated [00:28:00] pretty easily with a single dose of a oral medicine called fluconazole. And so we wouldn’t wanna deprive patients from this really important class of medicines that have important, meaningful heart and kidney benefits.
Because of the concern about potential yeast infections, that it would only be a concern if somebody just had real, really recurrent refractory yeast infections that we would avoid that class of medications. So I think sometimes there is an overconcern about side effects and people put more emphasis on being worried about side effects, and they underestimate the tremendous benefit that they would get from these medicines.
So it’s really important that we treat women the same as men with the guideline directed medical therapy agents that we have.
Sudipah Sarkar: Could you touch on a little bit about the role of non-statin medications for lipid lowering and when those might be indicated?
Erin Mikos: Yeah, so we know there’s a proportional relationship between the lower the LDL cholesterol and the risk of cardiovascular disease.
For every approximate 40 [00:29:00] milligrams of deciliter or lower LDL one can reduce the major adverse cardiovascular events by 22%. It’s pretty consistent and lower is better. We see an benefit all the way down to 10. There’s no LDL that’s too low, so it really seems to be about LDL lowering and not necessarily, the agent that we use now, statins are still always the first line therapy because we have four decades of experience with them with safety and efficacy. Most statins are all generic and cheap, and so most guidelines say start with a statin. But if we I mentioned earlier that we have risk-based targets for LDL thresholds.
For higher risk patients, we wanna get to lower goals with LDL. And so if we’re not able to get there with maximally tolerated. Statin. Either someone’s already on the max dose or somebody’s having side effects and can’t go to the max dose. The good news is that statins are not the only game in town.
We have some other oral medicines, ezetimibe, MEPA, doic acid, and [00:30:00] we have really potent injectable medicines. These PCSK nine inhibitors. And alizarin that can substantially lower LDL. They can also have some modest effect on a particularly risky type of cholesterol called lipoprotein little a, that all patients should also have that measured at least once.
And so depending on where someone’s starting and where their goal LDL is based on their risk, we can use combination therapy. And I’ll mention in the racing trial, which was done in Korea some patients of Asian East Asian ethnicity tend to have more statin associated side effects. And in that trial they looked at a lower dose of statin Rosuvastatin 10 plus a non-statin ezetimibe 10 compared to a higher dose of statin Rosuvastatin 20.
And they showed that the combination. Had similar reduction in cardiovascular events and even better LDL control and less stopping of the medicine than pushing the statin to the highest dose. So I think we can, should use combination [00:31:00] therapy much more commonly in lipid management.
We’d use it. Very commonly in blood pressure. If someone’s blood pressure is above one 60 over 90, we’re thinking about two agents of blood pressure out the get go. Often in combination therapy. The same thing with lipids. If somebody is starting very high often we will need combination therapy to get to these lower LDL targets.
Sudipah Sarkar: Dr. Erin Mikos, thank you for joining us today and for such an informative discussion.
Erin Mikos: Oh, thank you so much for having me on your program. I enjoy talking with you today.
Sudipah Sarkar: I’m Dr. Sudi Sarkar, and you’ve been listening to Diabetes Deconstructed.
We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information visit Hopkins diabetes info.org. We love to listen from our listeners. The email address is Hopkins diabetes info@jmi.edu. Thanks for listening.
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- Home - | - Episode 52: Gestational Diabetes and Marginalized PopulationsIn Episode 52, Dr. Sarkar welcomes Dr. Michelle Ogunwole, MD, PhD, who will speak with us about gestational diabetes with a special focus on marginalized populations. Dr. Ogunwole is an assistant professor of medicine at the Johns Hopkins University School of Medicine and faculty member at the Johns Hopkins Center for Health Equity. She is a health disparities researcher, social epidemiologist, and general internal medicine physician who has additional board certification in obesity, medicine and lifestyle medicine.
She has advanced training and quality improvement in patient safety science. Dr. Ogunwole is research is focused on health disparities and maternal health outcomes among African American women specifically in the role of the general internist in optimizing chronic medical conditions in the preconception period, postpartum chronic disease and long-term health outcomes related to complications of pregnancy, African-American women’s experience with the healthcare system and barriers to primary care follow-up after pregnancy, and creating equitable community-driven quality improvement interventions around the transitions of care, from obstetrics to primary care for racial and ethnic minorities who experience medically complicated pregnancies.
Download TranscriptTranscript: Episode 52: Gestational Diabetes and Marginalized PopulationsSudipa Sarkar: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Sudi Sarkar at Johns Hopkins. We develop this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkins diabetes info.org.
Today we are excited to welcome Dr. Michelle Ogunwole MD PhD, who will speak with us about gestational diabetes with a special focus on marginalized populations.
Dr. Ogunwole is an assistant professor of medicine at the Johns Hopkins University School of Medicine and faculty member at the Johns Hopkins Center for Health Equity.
She is a health disparities researcher, social epidemiologist, and general internal medicine physician who has additional board certification in obesity, medicine and lifestyle medicine.
She has advanced training and quality improvement in patient safety science. Dr. Ogunwole is research is focused on health disparities and maternal health outcomes among African American women specifically in the role of the general internist in optimizing chronic medical conditions in the preconception period, postpartum chronic disease and long-term health outcomes related to complications of pregnancy, African-American women’s experience with the healthcare system and barriers to primary care follow-up after pregnancy, and creating equitable community-driven quality improvement interventions around the transitions of care, from obstetrics to primary care for racial and ethnic minorities who experience medically complicated pregnancies.
Welcome, Dr. Michelle Ogunwole.
Michelle Ogunwole: Thank you so much for having me. I’m thrilled to be here.
Sudipa Sarkar: Thank you for joining us. So I wanted to start off with some general questions. So first I’d like to ask you to please give our audience a general overview of what is gestational diabetes.
Michelle Ogunwole: Sure that’s a great way to start. Gestational diabetes is a special type of diabetes that develops during pregnancy. So it’s not the diabetes that people have before pregnancy, but the one that you only get during pregnancy. And it happens when the body really can’t handle the sugar. That’s in our bodies as well as usual.
It usually goes away after birth. But it’s also an important signal about women’s long-term health and if it’s useful, sometimes I think about a little bit of a metaphor about how, we can think about gestational diabetes. If it’s useful, then I sometimes share that with people.
I think about a drill sergeant, I was in drill team growing up, so I think about that. So during pregnancy, I’d say that your insulin is like a drill sergeant and its job is to tell the glucose where to go move it, get inside the cells. But when the : pregnancy hormone comes along, it acts like a bunch of new rebellious recruits who don’t really wanna listen.
And so you think that, trimester after trimester, as you grow in your pregnancy, you’re getting more and more of these recruits and they’re. Starting to ignore orders, they’re dragging their feet, they’re pushing back. And so the drill sergeant insulin is having a harder time managing them.
And so they’re having to yell more and louder and work harder. And, eventually the recruits stop responding. So that’s basically how I explain what insulin resistance is. And that can happen in pregnancy. And some people get gestational diabetes, right? And some people don’t. And I think there’s a lot of factors as to whether or not your drill sergeant and your pancreas, which supports like your insulin is able to handle those recruits as they grow. That’s one of the ways that I try to explain it to people.
Sudipa Sarkar: That’s very helpful. What risk factors might make someone more susceptible to : developing gestational diabetes?
Michelle Ogunwole: That’s also a great question. There are things like your medical history. We know that weight overweight and obesity, carrying kind of excess fat in our bodies definitely increases the risk. There’s other things like having a family history of diabetes. As well as, any prior pregnancy that you have with gestational diabetes definitely increases the risk in your next pregnancy.
And then we know that certain groups of people are more likely to get gestational diabetes. Black, Latinx, Asian and indigenous women are more likely to have the diagnosis or. To have less control of their glucose if they get gestational diabetes. But that is usually related to the social risk factors or social things that go along with being members of some of these communities.
The other one I would say too is just because diabetes is gestational diabetes and diabetes is so closely related to : nutrition as well. When you think about people who have limited access to healthy foods and have less resources and obtaining some of those healthy foods also, or higher risk.
Sudipa Sarkar: So it sounds there are risk factors that predispose people to gestational diabetes. So weight family history and then social factors and economic factors. Can you tell us a little bit more about these social and economic factors , that play a role in gestational diabetes, in including nutrition access?
Michelle Ogunwole: Yeah, that’s a, it’s a good point. I think that it’s. One of the things I like to say is a lot of these things are related to one another. In research we think of the root cause of all of these things. You think about, a tree and the roots that are in the ground and everything that spouts off the tree, then we can start to think about is structural kind of disinvestment in certain communities. We also refer to that as structural racism. Kind of the totality of all of the ways that : structures and systems are set up to make certain communities fail in certain communities thrive. Some of those dis investments that have happened along the course of history for certain communities.
I do a lot of work with black and African American population. Thinking about things, as far as chattel slavery and then Jim Crow and , even the GI Bill not being open to black people coming back and how redlining, which is when certain groups or black people were denied access to home ownership.
Because of discrimination, all of these things really set up communities to not be able to obtain generational wealth. Also it sets them up to be in cycles of poverty and then that poverty from that tree, if you think about going up and. The things that kind of bloom, the leaves that you see come off when you don’t have access to resources it’s really difficult for you to make great choices in terms of even things like : your nutrition. We talk a lot about as a doctor and trying to help people to make healthy choices, but in order to make a healthy choice, you have to have a healthy choice. And not everybody has access to healthy choices based on some of these factors.
Things like that really. Contribute to whether or not you can buy healthy foods when you’re supposed to, whether or not your neighborhoods are safe enough to walk and do the exercises that you need that support your overall health and your healthy weight. There’s other kind of contributors , in the environment that might make it more stressful to live in an environment.
Certainly anybody who’s had some of those experiences growing up when you have limited socioeconomic resources or just money, this is the point to say if you have limited means. it’s stressful. It’s stressful to be poor. It’s stressful not to be able to afford things.
And we know that kind of chronic stress also affects our health, our weight, and things like diabetes. So we have research that supports those ideas. Hopefully, I’m trying : to paint a picture of what the roots of this tree look like and how that tree grows.
And what we see on the outside is different risks for different communities of things like gestational diabetes based on this.
Sudipa Sarkar: Thank you. That really helps kinda build a very comprehensive picture of all of the factors and variables that can affect women’s health specifically when it comes to gestational diabetes.
Could you discuss a bit about why blood glucose control is so important. During pregnancy for someone who has gestational diabetes and what are the major types of treatment that are available for women with gestational diabetes?
Michelle Ogunwole: Yes. Blood sugar control in pregnancy is extremely important. I would say that. In terms of the baby’s outcomes, of course we know that how high your blood sugar is and how out of control it is really affects the complications that you have at birth. Whether your baby : is much bigger than they’re supposed to be, we call that large for gestational age, which can affect a lot of things related to your delivery outcomes and make it difficult with vaginal deliveries and for complications to occur.
And there’s other more serious complications in terms of the early pregnancy and the formation of the organs in the baby itself. We know that having poorly controlled blood sugar can affect that development of organs for the baby. It’s really critical. That we, have really tight glucose, there’s the forming of the baby and the complications , even the complications, the birth complications that can happen.
And then too for the mom, we know that, people who have worse control of their sugar during pregnancy also have an increased risk of having diabetes after pregnancy. So it’s a really big predictor of the people who will go on to have diabetes. And we also know now that there’s more data. It’s really fascinating that what happens in pregnancy, it can actually be a predictor for your child’s future metabolic health. Whether or not they, your child has obesity, whether or not they may be at risk for diabetes can be determined by what happens during the pregnancy. And so that’s why the blood sugar is so important.
Going back to my metaphor about the unruly recruits. There are different levels of that unruliness, right? And so some people have only a few unruly recruits, and those are people who can maybe be managed with just diet.
They have gestational diabetes, but there are things that we can do to reduce their blood sugar. To the ranges that we would like during pregnancy, just through diet modification. That’s why working with a nutritionist is so critical because, you can really see it in real time. It’s incredible.
We have people who have more unruly recruits and sometimes they require more support to get them in order and that’s what I would call people who need insulin therapy to help them manage their blood sugar and pregnancy. And so there’s other medications that people might be familiar with.
Metformin is a pill that we also can use in pregnancy to support this overall approach to improving our body’s ability to handle the glucose levels, the sugar in our bodies. So those are the main treatment modalities. And then along with the diet piece, I’ll go back to that.
There’s some interesting studies that, and we know this true, this is outside of pregnancy, but physical activity can also be supportive in this. So like sometimes we’ll have people after big meals going to take a walk and there’s really people who do very well with that and supporting like this plan to get their sugar into a better controlled range. And you may or may not ask me about this later, but it’s really fascinating because now we have more and more women wearing these continuous glucose monitors, which allows you to see the effects of your blood sugar changing in real time. It’s a monitor that’s it’s painless and you attach it to your body and it’s continuously measuring your blood sugar all the time that you’re wearing it and you get alerts on your phone about what your blood sugar is in the moment. You can actually eat something and then see what happens to your blood sugar. You can take a walk and see what happens. I think that can be really empowering and helpful for people to really see the way that diet and activity can influence your blood sugar and how this is happening all throughout the day.
All of the things that you do really contribute to that, even the stress and the amount of sleep, all of those things come together to contribute to these rises and falls. So it’s nice for people to be able to really see that in real time.
Sudipa Sarkar: Are goals for women who are pregnant with gestational diabetes different , as opposed to someone who’s not pregnant but has diabetes and when would someone need medicationoutside of metformin more than diet and exercise intervention? Are the glucose goals different between those two groups of people?
Michelle Ogunwole: When we think about the way that we design our targets for glucose during pregnancy… because of everything that’s going on with the pregnancy, we have much tighter blood sugar parameters for pregnancy because of the baby’s organs forming and all of these things that are happening. And so yes, we do have slightly different targets in pregnancy.
Non-pregnant individuals, we are still looking at the same parameters. So when you wake up after you have slept and you haven’t eaten, we look at fasting blood sugar. We tend to look at our sugar right after we have meals one or two hours after that. And so we’re looking at the trends for all of these things.
I’m very interested in continuous glucose monitors, they’re really interesting because they can give us a little bit more information too. Even for that, when we set the parameters, we actually 1: set them differently for pregnant individuals to when they alarm, and we have goals for how often we want them to be in the ideal range for blood sugar for pregnant women. And that’s how we also guide our therapy. So it’s really interesting to see that too.
Obviously diet and exercise is one component. Then we sometimes add things like metformin which can help with our overall, sensitivity, to insulin and in our bodies.
And then we have insulin itself. We sometimes, despite our best efforts, especially with the pregnancy growing, we have this growing pregnancy every week, as that placenta grows, that baby grows, we just have more and more of those unruly recruits. That’s what I keep saying.
So it’s just. At some point, sometimes we cannot manage it and we actually have to give people insulin to help them manage their blood sugar. And particularly as the trimesters progress,we really see that increased need for insulin in the later trimesters, which makes sense. Because the baby’s growing as well.
Sudipa Sarkar: It sounds like there’s three phases that we think of for the woman with gestational diabetes kind of preconception period during the pregnancy and then post-delivery. And so in an ideal situation, what does the care of the woman who has had gestational diabetes look like after delivery in kind of 1, 5, 10, 20 years later in terms of, helping to prevent complications or the cardiometabolic diseases that we see that are associated with gestational diabetes.
Michelle Ogunwole: That’s a great question. Gestational diabetes, which is diabetes and pregnancy increases the risk of developing diabetes outside of pregnancy, and that is by seven to 10 times. So, it’s pretty significant. And we talked a little bit about the things that predict whether or not you will go on to get diabetes, so your blood sugar control in pregnancy, whether you needed insulin. These are the kinds of things that really predict whether you’ll go on to have diabetes in, after your pregnancy. But in addition to that we also know that gestational diabetes independently increases the risk of other diseases like cardiovascular disease. So, things like, stroke, high blood pressure having a heart attack. We know that this risk is like one and a half to two times higher for people who’ve had gestational diabetes.
It really is important I talk about pregnancy as a stress test, which kind of reveals some things to us. So when you get these diagnosis, it reveals something, but it’s also showing us that there is an important opportunity, I think to intervene to try to prevent these kind of long-term diseases from developing, and we can, and I think that’s what’s exciting about the work that I do, is that we can support people so that we could try to prevent progression to some of those outcomes that I talked about. Also, if they want to have another pregnancy right, that we can put them in the healthiest state that they can be to go into that next pregnancy and hopefully reduce the complications from happening again.
The other predictor after people have their babies, they also get another test of their insulin sensitivity or how well their body is managing glucose after they’ve had the gestational diabetes. Because this diagnosis usually goes away for a lot of people after the baby is delivered. So, we do another test about one to three months after delivery. It’s called an oral glucose tolerance test. We do another one to check to see if you still have some clues that your body is not managing your sugar as well as it should, even though the baby’s delivered.
Sometimes people have borderline or higher numbers, and that also predicts whether or not they end up getting diabetes in the long term as well. Some of the work that I have been doing is thinking about, what can we do in that or that postpartum period to reduce the risk of these chronic disease happening.
And one of the things I’ll say is that a lot of people don’t even come back for those follow up tests to check to see if they have that continued problem with their glucose. I’d say 50% of people don’t always show up for that test. That’s one thing that I think is really important that women who’ve had gestational diabetes recognize that the risk isn’t over just because the baby has been delivered. And so it’s really critical that we follow up with your primary care, your ob, your primary care team, just to continue to monitor that risk and see if there’s some things that we can do.
Then going back to diet and exercise and what we know is that, and maybe people have their own experiences with this, but we gain weight during pregnancy. That’s common. Some people gain more than the recommended amount as well, and those are kind of predictors of whether you get these chronic diseases too.
We often have weight gain during pregnancy. And then we have postpartum. And what we would like is for people to return to their pre-pregnancy weights within a year. But a lot of people retain that weight. So we call that postpartum weight retention. And that also predicts whether or not you go on to have diabetes.
It can become a cycle where you think about when you have multiple kids, if you never lose that weight from the first baby, and then you go into your your next pregnancy and you gain weight and you never lose the weight and you go into your next pregnancy. So it can happen that way for a lot of people. I will tell you that I have been very humbled myself, I, after having children that it’s not easy. To just go back to your pre-pregnancy weight in a year. I could share personally, I’ve gained 60 to 70 pounds with each of my pregnancies despite trying to eat the best that I could and be active.
It still happens that way, and it’s not an easy thing to tell people to just lose all of that weight in a year. And really the idea is how do we support people to make small lifestyle changes, especially in the very early postpartum period when they’re already managing and dealing with so much.
Mostly everybody is sleep deprived and so it’s challenging to lose weight when you’re not getting rest. Some people are breastfeeding and they are really working towards making sure that they have enough calories and intake to support that and they’re just managing this kind of new normal of their life and dealing with kind of the hormonal changes that happen postpartum.
What it really is about is just having people make manageable changes. We start with things like trying not to drink soda trying to drink more water, trying to, get in a 10 or 15 minute walk once you’ve been cleared to exercise. Just small things that you can incorporate in that early phase that also make you feel more like yourself is really important. Then later on, discussing what other therapeutic options there are.
Sudipa Sarkar: It’s very insightful. I wanted to ask, you mentioned the oral glucose test that’s done after pregnancy to see whether or not that person still is not responding to insulin in their own body. Are there other tests that are less cumbersome? The oral glucose tolerance test is a tough test, especially for someone who’s just given birth, a few weeks before.
Michelle Ogunwole: Outside of pregnancy we use a hemoglobin A1C, which is like a three month average of what your blood sugar has been doing in your body. We cannot use that in pregnancy just because that test relies on factors that change in pregnancy.
But after three months, we actually do use that test. So for people who haven’t had an oral glucose tolerance test, I will. Give them a hemoglobin A1C later. I do know that there are scientists working on this very issue right now. People don’t like doing the oral glucose tolerance test in pregnancy. It’s not a fun test. I know that there are some researchers that are working on a hemoglobin A1C that can be : during pregnancy. So that’s a grant funded study in Boston. I know that they’re working on that, so I think that’ll be very paradigm shifting. The other thing is, and I know that we do this sometimes in our high risk OB clinic because some people, let’s say if they have other complications like hyperemesis, which ratu, which means that you’re throwing up all of your pregnancy, and it’s just more than more than typical kind of morning sickness. It’s just excessive. It’s really difficult for people to handle the oral glucose tolerance test, which requires you to drink a very un tasty but sweet beverage. And some people really can’t tolerate that.
And so it’s been really interesting to think about, again, about continuous glucose monitoring and how some people we’ve been able to extrapolate for some people who are not in the range, that they may have some dysfunction in how they’re handling glucose from that test.
We know that those tests are the continuous glucose monitor. There was a big study on it actually to see, hey, if we use continuous glucose monitors in pregnancy versus having people stick prick their fingers, do we have better birth outcomes? And there wasn’t really a difference in birth outcomes, but the thing is that the patients liked it better. It was less finger sticks and stuff. That’s also promising and that matters. I think it matters a lot about whether people are willing to accept a therapy because it helps us to get the data that we need. That’s something that I’ve seen used for people who really can’t tolerate the oral glucose tolerance test. And in my own work, we’ve been doing some postpartum measurements of the oral glu using continuous glucose monitoring. And there’s another huge study in Boston that’s looking at that. And I think in a couple years we’ll have enough data to say how we can, use the measures that we get from continuous glucose monitoring to actually diagnose people. I think all that’s in the pipeline.
One of the challenges with CGM, both inside of pregnancy and outside of pregnancy it’s not covered unless you’re on insulin. We have challenges getting it for people. Those people let’s say they don’t tolerate oral glucose tolerance test, but they’re not on insulin. Because we haven’t diagnosed them what happens is the : clinic has a sample or I have a sample, so they get to have it. We’re actually doing a policy brief on continuous glucose monitors for patients who are not on insulin in pregnancy, because I think that population is much more likely to get support because they still need tight glucose control, even if they’re not on insulin. It’s so important for the baby. It’s a easier narrative cell when you go to testify and say you can really paint a picture for people. I think that they’re using. It just depends. Like they have type two diabetes and they have poor control, and they’re seeing those numbers early. They’ll still slap it on there early because they already know that these people have type two. But for gestational diabetes, they have to have the diagnosis first, which typically happens around 8 weeks. Then it becomes this challenge of do they need insulin or not? Is it gonna be covered? So I think that’s what is tricky.
Sudipa Sarkar: Dr. Ogun Ole. How can we as clinicians incorporate a history of gestational diabetes when we’re seeing a patient in clinic who’s had gestational diabetes? How do we incorporate that knowledge into helping the patient reduce their risk of cardiometabolic diseases in the future? And how can we better close the gap between different populations of patients, close the gap from someone who comes from a more marginalized population.
Michelle Ogunwole: I think number one, as non obstetric folks like primary care endocrine I think one of the important things is just making sure that we’re asking the questions because sometimes we feel like pregnancy is not necessarily our lane because we have our obstetric colleagues, but for providers that take care of women across their life course, so we see them, in other stages of their life when they’re trying to get pregnant, potentially when they’re postpartum. It’s really important to incorporate that in our history, all their complications from pregnancy. We can get a lot of clues from that. So I think number one is just asking the question. I think it would be surprised that how much it’s left off of our primary care evaluations. So that’s one piece.
And then recognizing that if they have had certain complications. In this example we’re talking about gestational diabetes, then it does put them at risk for diabetes. So we should be more attentive in our screening for diabetes for those populations. That’s another piece.
We also wrote a perspective piece for, about this very topic and how we really should consider how these things that are showing up in pregnancy really are almost a warning or something that we should really take seriously as we think about our other therapeutic options, particularly with women in with obesity. And we have different medication approaches now, and whether or not considering gestational diabetes because we know obesity increases the risk.
We wrote a piece that said we should really take this into account when we’re considering whether or not to escalate therapies for managing obesity. So now we have a lot of different options for that. There’s a new class of medications that people are familiar with or may have heard of the GLP-1s. So things that people might have heard of Ozempic or Wegovy. The way that we prescribe these, this is outside of pregnancy, usually has to do with obesity and then having, another disease that is related to obesity, that’s putting your health at risk.
And so we said, gestational diabetes is an indicator right of some other dysfunction. And for reproductive age women, we should really consider this as a reason to escalate and be more aggressive in our approaches to giving them options for weight management. And there’s other studies going on about postpartum populations, people who are struggling with obesity and the use of these medications, which right now, they’re not approved for use when you’re breastfeeding. But in people who aren’t breastfeeding, were there’s studies that are looking to see, do those medications reduce the risk of developing type two diabetes.
So we know things like metformin and certainly diet and exercise do. There’s new kind of studies to seeing what else does. So I think just making sure that we’re really thoughtful in identifying these people and then making sure that we are creating plans that are aligned with their goals and offering them the full kind of array of options available to them.
To your point, I think that the same way I said, that kind of nutritious foods and all these things are not always available to certain groups. I would say the same thing is true about some of our newer medications and the the things that we have to treat obesity and potentially prevent and improve diabetes and its control.
Those things are not always available to certain populations based on their insurance status and some other things. The medications can be very pricey as well. I think there’s just a lot of work to do. The work that I’m have been really interested in is making sure that as we design therapies and options to support healthier lifestyles for people which ultimately improve their risk of getting diabetes, that we also think about how our systems and structures can be accountable in helping to support that process. How should our hospital systems and how can government programs really support in giving resources for healthy food so that way when we prescribe them, people have a way to get them. That’s the work that I’ve been interested. I think that whatever things that we offer patients, particularly when we’re talking about dis health disparities or health equity, we have to ask ourselves, what is the structural and system solution that can support this recommendation that I’m giving? And work really hard to identify that, whether that’s with our social workers or through other programs or assistance programs that can support people in healthy eating as well.
Sudipa Sarkar: Dr. Ogun Ole, thank you so much for a wonderful conversation. This is very nice, very helpful.
Michelle Ogunwole: Thank you so much for having me. This has been delightful.
Sudipa Sarkar: I’m Dr. Sudi Sarkar and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit Hopkins diabetes info.org. We love to listen from our listeners. The email address is Hopkins diabetes info@jhmi.edu. Thanks for listening and see you next time.
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- Home - | - Episode 51: Diabetes and MenopauseIn Episode 51, Dr. Sarkar welcomes Dr. Tina Zhang, who will be talking with us about diabetes and menopause. She’s an assistant professor of medicine at Johns Hopkins University School of Medicine. She currently serves as co-director of the Johns Hopkins Women’s Wellness and Healthy Aging Program, the co-director of the Medical Education Pathway for the Johns Hopkins, Osler and Bayview Internal Medicine Residency Programs. She also serves as the director of the Academic Women’s Health Track of the Johns Hopkins General Internal Medicine [00:01:00] Fellowship. Dr. Zhang has primarily focused her clinical work, research, and educational efforts on improving women’s health education and care with a special focus on menopause. She is a Menopause Society certified menopause practitioner, and has created a women’s health consultative practice within the Johns Hopkins Division of General Internal Medicine to support women through the menopause transition. Her research has focused on various women’s health topics including menopause, women’s health curricula, and HPV vaccination.
Download TranscriptTranscript: Podcast 51: Diabetes and MenopauseSudipa Sarkar: [00:00:00] Welcome to Diabetes Deconstructed. a podcast for people interested in learning more about diabetes . I’m your host, Dr. Sudi Sarker at Johns Hopkins University. we developed this podcast as a companion to our Patient Guide to Diabetes website. if you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkins diabetes info.org.
Today we’re excited to welcome Dr. Tina Zhang, who will be talking with us about diabetes and menopause. She’s an assistant professor of medicine at Johns Hopkins University School of Medicine. She currently serves as co-director of the Johns Hopkins Women’s Wellness and Healthy Aging Program, the co-director of the Medical Education Pathway for the Johns Hopkins, Osler and Bayview Internal Medicine Residency Programs.
She also serves as the director of the Academic Women’s Health Track of the Johns Hopkins General Internal Medicine [00:01:00] Fellowship. Dr. Zhang has primarily focused her clinical work, research, and educational efforts on improving women’s health education and care with a special focus on menopause. She is a Menopause Society certified menopause practitioner, and has created a women’s health consultative practice within the Johns Hopkins Division of General Internal Medicine to support women through the menopause transition.
Her research has focused on various women’s health topics including menopause, women’s health curricula, and HPV vaccination.
Welcome Dr. Zhang.
Tina Zhang: Thank you so much Dr. Sarkar. so wonderful to be here.
Sudipa Sarkar: Thank you for joining us. I wanted to start off and ask you to please explain the terms perimenopause and menopause, if you could help us understand what they are and the differences between the two.
Tina Zhang: Absolutely . I think that’s a great place to start. Menopause is a [00:02:00] clinical diagnosis and it’s a retrospective diagnosis. We define menopause as the point where a woman has gone 12 consecutive months. Without a menstrual period, and in the United States, the average age is around 51. And after they hit that 12 month mark of no menstrual cycle, they are in menopause.
And then after that period, they’re considered post-menopausal. Perimenopause or what we actually like to use the term, the menopause transition, that is the transitional phase leading up to the point of menopause. This is where women’s body is producing less estrogen, less hormones. This period can last many years and you are gonna see a lot of, symptoms like mood swings, hot flashes, sleep disturbances, et cetera. But all of that is part of the menopausal transition that can start as early as in your mid to late thirties. It can transition all the way until, a woman actually hits menopause.
Sudipa Sarkar: [00:03:00] Dr. Zhang, how does diabetes impact age of menopause or even the symptoms of menopause ?
Tina Zhang: On average, diabetes by itself doesn’t impact the age of menopause onset. Like I mentioned earlier, our average age is about 51, but what we do see is that women who have diabetes who may potentially have a higher BMI or more adiposity, they do have more severe and more frequent symptoms of menopause in particular the hot flashes and the night sweats, that’s what we call our vasomotor symptoms of menopause, those seem to be more severe in the pre and peri menopause stage in patients who may have, more central fat distribution, which interestingly is actually reversed in the post menopause period.
There’s some data also that I should mention, that type one diabetes patients may [00:04:00] experience earlier menopause. We’re still not sure exactly why, but we think there may be an autoimmune component to it. In general, diabetes by itself doesn’t really impact the onset, but it can make symptoms worse. It’s important to know what the symptoms associated with menopause are, and unfortunately there’s a lot of them.
The most common symptoms associated with menopause are what we call vasomotor symptoms of menopause. This is your night sweats, your hot flashes, and night sweats are really just hot flashes at night. We also have what we call the genital urinary syndrome of menopause, and that is symptoms like vaginal dryness.
Vaginal irritation, discomfort, burning, increased risk of developing UTIs, urinary incontinence, et cetera, and those symptoms worsen with time. In women, the majority of the other symptoms will get better, but are gender urinary. Symptoms do worsen as patients [00:05:00] get older. A hallmark of menopause are the menstrual irregularities.
Sometimes that’s just the first thing patients present with. They aren’t having any hot flashes. They’re not having any night sweats, but they’re just starting to notice that their menstrual cycles are starting to space out or become more irregular or all of a sudden they got really heavy one month and super light the next month.
And that can be, one of the. Defining symptoms of menopause that we see for sure. Other things to be aware of. I mentioned mood fluctuations just associated with the hormonal changes. Mood swings are very prominent sleep disturbances. We see a lot of issues with sleep. In menopause, hair loss and skin changes, those are things we’re going to see as well.
It can really impact libido, so women can have lower libido. And then one thing I see all the time is just brain fog. Just feeling like you’re starting to. Not [00:06:00] remember words or just feeling like it’s hard to concentrate and feeling like the job that they were doing at work that initially wasn’t so hard, all of a sudden it’s just becoming harder and they feel like their brain is not functioning the way it usually does.
That is something we see very often as well. There’s just estrogen receptors everywhere in the body. Anywhere it’s in the body, it’s, you’re gonna see it impacted. But those are some. Regular and some common symptoms that we see associated with menopause.
And this, I know now that we stopped, but it’s not fair. It’s like everything, it’s like everything. But I will say I do think it’s very important as providers also to make sure we’re ruling out other causes and making sure that, we are being thorough and proactive and clarifying that symptoms are due to the menopause transition and not something else as [00:07:00] well.
Sudipa Sarkar: Can you tell us a little bit more about how perimenopause or menopause might impact women with diabetes? Specifically in terms of areas like heart health, blood pressure, or cholesterol?
Tina Zhang: In younger, healthier patients, estrogen has a protective effect on cardiovascular health. What we see during menopause is that as the estrogen declines, that can lead to changes in cholesterol. So it leads to the bad cholesterol or what we call the LDL. It gets higher. The good cholesterol, which we call the HDL, that gets lower and it can also elevate blood pressures as well. Those changes combined with the risks associated with diabetes can then lead to a higher risk of developing heart disease.
In patients who have diabetes, we want to really be careful of monitoring the eyes every year. Changes in menopause can impact [00:08:00] vision. And estrogen levels can lead to dry eyes, which can impact your vision as well. That is just another thing that I think is important for patients who have diabetes to be aware of as they’re going into the menopausal transition, that sometimes dry eye can be associated with menopause.
And then bone health becomes really important as well. Especially our type one diabetics where we know there’s an increased risk of osteoporosis and increased risk of fractures, estrogen’s really protective of the bones. And as you go through menopause and your levels are going down what we can see is that menopause and diabetes can negatively impact bone density as well.
Sudipa Sarkar: That’s very helpful. How does weight gain during menopause impact diabetes management? And is there an increased risk of developing diabetes in women after menopause?
Tina Zhang: Many women gain weight during the menopause transition. We see that all the time in [00:09:00] our consultative practices and during menopause consultations. I think weight gain is one of the top three complaints that we see in clinic, but most women are gaining weight during menopause, not because of menopause itself, but more related to aging and lifestyle changes rather than menopause. That is one thing that I did wanna clarify. One thing that we chat with patients about a lot is that weight gain is maybe more related to the aging process than the hormonal fluctuations. That being said, what we do know is that estrogen plays a big role in how fat is distributed in the body.
With menopause, we see an increase in central fat distribution or central adiposity. And because of that, that can lead to worsening insulin resistance and therefore that really impacts women with diabetes because if you’re more resistant to insulin, it can make glucose management more difficult.
I will say [00:10:00] also that because of the fluctuations in hormones associated with menopause in particular the menopausal transition, the hormones while estrogen’s going down, it’s roller a rollercoaster ride of hormone fluctuations. Those fluctuations can sometimes impact blood sugars. That can be one of the things that patients can see that there, there’s more fluctuations in blood sugars to be aware of during that menopausal transition.
Sudipa Sarkar: Great. And then Dr. Zing, I think you answered this, but do you see that in women post menopause, are they more at risk of developing diabetes?
Tina Zhang: Yes, and the reason for that is more related to the fact that we do see weight gain associated with the menopausal transition and just aging. As a result of the weight gain that is then associated with more insulin resistant and a higher risk of developing diabetes.
But I will [00:11:00] say that is just one potential risk factor. It’s usually o, other potential risks are also playing a role here as well. If they have a history of gestational diabetes in the past or other, history of PCOS, things like that could also impact their overall risk for developing diabetes.
So those are things that we do. Monitor for during our menopause consultations, we’ll ask about their obstetric history and, see if they have a history of PCOS or things like that, that can also affect their risk of developing insulin resistance or diabetes for patients.
Sudipa Sarkar: You touched a little bit earlier about heart disease and bone health in women during menopause and after menopause.
Do you find that for women with diabetes in menopause or after menopause, are they more likely to be diagnosed with heart disease in low bone densities?
Tina Zhang: Absolutely. I think menopause independently [00:12:00] by itself can increase the risk of heart disease and osteoporosis, but then in combination with diabetes, I think these risks really magnify, you know, I think patients who do have diabetes have a higher risk of developing heart disease because diabetes by itself is a risk factor for heart disease. And then you add on the aspect of menopause to that and both can definitely negatively impact bone density because again, estrogen’s protective of the bones.
So during the postmenopausal phase where you’re losing estrogen, you end up losing bone mass. And with type one diabetics in particular we see associated with increased risk of osteoporosis and fractures.
Sudipa Sarkar: You talked a little bit about changes in estrogen in the perimenopausal period, and then in menopause and then post menopause and how they impact blood glucose in women with diabetes are the changes in blood [00:13:00] glucose and that fluctuation similar in those three phases. Could you comment on that?
Tina Zhang: During the perimenopausal transition, like before they’ve hit menopause, there’s very wide fluctuations in hormones and as a result it can impact blood sugars more. Once patients hit menopause and then are in the postmenopausal stage, some things tend to even out a little bit. But even within the post menopause phase, we have different stages. There’s early post menopause and late post menopause, we do still see some more fluctuations during the early post menopause phase and patients usually have still more menopausal symptoms, whereas once they’re in that late post menopause phase symptoms really are very stable. And those vasomotor symptoms like the hot flashes and the night sweats, by then, those symptoms are hopefully mostly [00:14:00] gone.
And as a result, blood sugars, typically the fluctuations that can be seen, With that, you will stabilize a bit, but once you get into post menopause, then you have the risks associated with more insulin resistance, higher risk of weight gain, changes in your cholesterol, blood pressure, that can lead to, higher risk of developing heart disease or metabolic syndrome.
Sudipa Sarkar: What options are out there for women that are not medications that might help manage blood glucose changes in the perimenopausal period during menopause and even after menopause?
Tina Zhang: Great question. In particular for non- medication options, I think the most important thing that we counsel patients about almost really every single day is about the importance of exercise. And I think that’s something that we all know, I personally feel like I need to [00:15:00] exercise more. I tell my patients to exercise more. I’m like, I need to exercise too. I think in this particular case, exercise is really important for menopause. There is data that shows that exercise can help to reduce the severity of menopausal symptoms. We know for a fact that aerobic activity is really important for heart health. We know for a fact that strength and weight training is really important for bone health. I think, exercise in general is not only gonna help with menopausal symptoms, it’s gonna protect your bones, it’s gonna protect your heart, and it’s going to help with weight loss. And I think overall that is probably the most important non-medication strategy for managing menopause and blood, diabetes, et cetera.
And then I think, nutrition plays a important role here, obviously in diabetes, just being very [00:16:00] careful on eating a balanced diet, but not having too much sugar in the diet. And then thinking about limiting really refined carbohydrates, limiting added sugar, et cetera. But we also can see that sometimes spicy foods can cause worsening hot flashes or night sweats at night. Sometimes there’s certain foods that can trigger menopausal symptoms for some of those patients. Identifying what those triggers are can be really helpful.
Sudipa Sarkar: Can you discuss more about treatments for menopause and how this could impact glycemic management.
Tina Zhang: When it comes to menopause treatment, I like to bucket them into three categories. The first one we discussed already, more lifestyle modifications and mind body techniques. Those things include exercise, a healthy diet. Things like cognitive behavioral therapy.
But in terms of medication specific I think about them in two buckets. The first one [00:17:00] is hormone treatment options, and then the second bucket is our non-hormonal treatment options. Of the two hormone therapy is going to be the most effective treatment for our menopausal symptoms in particular, night sweats and hot flashes.
So when it comes to hormone therapy though there is a lot of controversy, about it. I think there’s been research in the past that have associated hormone therapy was with elevated risk of heart disease and breast cancer. It’s led to a lot of women not being able to get hormone therapy. It’s led to a lot of providers not feeling comfortable prescribing it or managing it. And that has really impacted care for women who are going through the menopausal transition, unfortunately. And what we know now is that in patients who are less than the age of 60 or within 10 years of menopause [00:18:00] onset who don’t have clear contraindications to being on hormone therapy, the benefits could outweigh risks in those patients who are having moderate to severe symptoms of night sweats and hot flashes. We have so many different options for hormone therapy. My preference is to choose the transdermal options because they’re safer than the oral estrogen options. But there’s a lot of nuances that come with hormone therapy and management for menopause that could be a whole podcast in and of itself, but I think the main takeaway is that hormone therapy is the most effective treatment for patients who are going to qualify for hormone therapy, and a lot more women do than we think. This is where I think it’s equally important for us to educate providers about which patients would be the best candidate for hormone therapy, for menopausal symptoms. And we always use evidence behind everything we do here at [00:19:00] Hopkins.
Then the other bucket is our non-hormonal treatment options. And actually there’s a whole toolkit. There’s so many options out there. Many of the options are things that we use all the time as internists that we forget about. So things like our antidepressants. Our SSRIs, which are antidepressants, can be very effective for helping manage symptoms. We have medications like gabapentin, which I know a lot of diabetics use because it can help with diabetic neuropathy, but it’s also very effective for helping with sleep disturbances associated with menopause. It helps to reduce both the frequency and the severity of night sweats associated with menopause. Gabapentin is an option that I use very often in menopause consultation clinic.
We also have some newer agents out there, like our Neurokinin three receptor antagonists. Those were FDA approved in 2023. it’s a new medication to help manage [00:20:00] hot flashes, but it’s really well tolerated. Patients do well on it. There’s really a quite a few options out there that are non-hormonal as well.
So that’s how I think about the two medications buckets, hormone therapy and non-hormone therapy. And then with regards to blood sugar in particular, hormone therapy is not going to really raise blood sugar. That’s usually not something that we will be worried about. And there’s some newer evidence out there I think there was a new meta-analysis that was published that show that it may improve insulin sensitivity. Again, it’s not really gonna impact blood sugar per se, in terms of concerns that it may make your blood sugars worse.
Sudipa Sarkar: What do diabetes and menopause intersect to impact mental health?
Tina Zhang: I think that mental health is really important during the menopausal transition, just because, number one, the symptoms of [00:21:00] menopause are just so uncomfortable that women are going through a lot, and I think that can really impact your quality of life, your relationships. At work, at home, your ability to focus, it can cause brain fog, et cetera. But I think the other thing to be aware of is there’s just so many hormonal fluctuations that’s associated with the menopausal transition, and that leads to a lot of mood fluctuations. The hormone changes leads to mood changes.
So the mood swings we see that often. We see worsening of anxiety, we see worsening of depression. And then on top of that, in patients who have diabetes, that can be a really big psychological burden as well. The fear of complications, having to monitor your blood sugar all the time. The combination I think can feel quite overwhelming.
Diabetes and then adding on all the hormone changes associated with menopause, that can lead to mood fluctuations as well. I think that’s just something that, number one, patients need to [00:22:00] be aware of that, these mood changes we are going to see in menopause and that you are not alone. We expect this and we have ways to help manage it. I think open communication with their PCPs or gynecologists or their menopause providers is gonna be really important. And just to know that there’s ways to help manage their physical symptoms, but also their mental health as well . Especially ’cause as I mentioned earlier, our antidepressants. Can be used not only to help with mood, but can also be used to help alleviate menopausal symptoms. That’s just something that I think, is gonna help patients who may have issues with mental health and struggles.
And I think, sometimes support groups can be really helpful, just whether it’s a diabetes support group or a menopause specific support group, just to help normalize the experience of what they’re going through, can provide some support and some guidance, and I think that can be really helpful as well.
Rita Kalyani: It’s interesting for people with diabetes you think that the recent evidence doesn’t suggest they go through [00:23:00] menopause earlier, but the symptoms could be worse, right?
Tina Zhang: Absolutely.
Rita Kalyani: Is that something you think we should be educating our patients with diabetes about ahead of time?
Tina Zhang: I definitely think so. It’s more related to insulin resistance and weight. The majority of the data that looks at severity and frequency of menopausal symptoms looks more associated with the weight side of things, and I think that goes hand in hand with diabetes. If you are overweight, that is definitely gonna cause worsening symptoms in the pre and peri.
Menopausal transition, but post menopause, interestingly, and I think it’s because when you have more adiposity, there’s more peripheral conversion into estro because you have more estrogen levels than someone who has a lower BMI post menopause. Your symptoms actually lessen, so it’s actually a little bit convoluted and confusing.
But I do think regardless, I think women. Even if they didn’t have diabetes, [00:24:00] should be informed about menopause. But in our diabetic patients in particular, knowing that they already have a risk factor for heart disease, now adding on the risks associated with menopause, that kind of compounds their risk. I think that is important to educate our patients about.
Sudipa Sarkar: Dr. Zhang, as we finish up our conversation, are there any thoughts that you’d like to share with our audience?
Tina Zhang: I think the main takeaway is that menopause is something that all women are going to go through. It’s a natural progression of aging, but unfortunately I feel like a lot of women are not prepared for this transition. I don’t think we talk about it enough. I don’t think we were prepared to go through the menopausal transition enough, and I don’t think providers are educated enough to support women going through the transition and to be knowledgeable about what all of the [00:25:00] options are to help them through this.
I think the main thing I would say to the patients who are listening is that if you want to learn more. Or if you are going through menopause and having symptoms, just know that there are so many resources out there that are evidence-based that are really helpful, both here at Hopkins, but also at other places.
And we’d be happy to help connect you with resources if needed.
Sudipa Sarkar: Dr. Tina Zhang, thank you so much. This has been a really informative discussion.
Tina Zhang: Thank you so much Dr. Sarkar.
Sudipa Sarkar: I’m Dr. Sudi Sarker, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our patient Guided diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit hopkins diabetes info.org. We’d like to hear from our listeners. The email [00:26:00] address is Hopkins Diabetes info@jmi.edu. Thank you for listening and see you next time.
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- Home - | - Episode 50: Diabetes DistressIn Episode 50, Dr. Kalyani welcomes Katie Lacy, who will be talking with us about diabetes distress and burnout. Katie is a registered nurse and certified diabetes care and education specialist at the Johns Hopkins School of Medicine Division of Endocrinology, diabetes and Metabolism. After earning a BS degree in psychology, she began working in the field of diabetes management in 2017 and graduated in 2022 from Johns Hopkins School of Nursing with an entry master’s into nursing. She’s currently pursuing her adult gerontology, primary care nurse practitioner doctorate at Johns Hopkins University School of Nursing, reflecting her commitment to expand her expertise and advance her practice, she currently practices in an outpatient clinical setting, focusing on education, optimization of diabetes technology, and promoting emotional wellbeing while navigating life with diabetes.
Download TranscriptTranscript: Podcast 50: Diabetes DistressDr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani, at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.
Today we are thrilled to welcome Katie Lacy, who will be talking with us about diabetes distress and burnout. Katie is a Registered Nurse RN) and Certified Diabetes Care and Education Specialist (CDCES) at the Johns Hopkins School of Medicine Division of Endocrinology, Diabetes and Metabolism. After earning a Bachelor of Science (BS) degree in psychology, she began working in the field of diabetes management in 2017 and graduated in 2022 from Johns Hopkins School of Nursing with a Master of Science in Nursing (MSN).
She’s currently pursuing her Adult-Gerontological Primary Care Nurse Practitioner Doctorate at Johns Hopkins University School of Nursing, reflecting her commitment to expand her expertise and advance her practice. She currently practices in an outpatient clinical setting, focusing on education, optimization of diabetes technology, and promoting emotional wellbeing while navigating life with diabetes.
Welcome, Katie.
Katie Lacy, MSN, RN, CDCES: Thank you so much for having me.
RK: We are so thrilled to have you here to talk about this topic, which I think is so important to discuss, but probably is not addressed as much as it should be, and that is a topic of diabetes distress and diabetes burnout. Could you start off by telling us — What is diabetes distress and what is diabetes burnout?
KL: Diabetes distress refers to the emotional and psychosocial burden of living with and managing diabetes. It can involve feelings of stress, frustration, even fear. The fear could be related to, fear of complications or concern that maybe you will be judged in the medical setting based off what your diabetes looks like. It is really personalized to you, as to what is causing that stress in relation to your diagnosis.
Diabetes burnout is when you reach the state of exhaustion of either physical or emotional exhaustion from stress. You could feel powerless or hopeless to the point that you start to disengage from self-care activities. Maybe you miss appointments, start making unhealthy choices with eating or uncontrolled eating due to the state of exhaustion from the stress.
RK: Wow. It is a spectrum then between diabetes to stress, perhaps more common in people with diabetes to the point of diabetes burnout where there’s exhaustion and it sounds like impairment in activities of daily living. How common is diabetes distress?
Does everyone with diabetes experience this?
KL: It is pretty common, but not everyone experiences diabetes distress. If you look at statistics, they can vary. For someone with type 1, it could be anywhere from 22 to 42%, and then if you have type 2 some statistics show that it’s over 60%. So most likely while you are waiting for your appointment, somebody else in the waiting room has also experienced this type of stress.
It is definitely something that I see in varying levels every day in practice. It does not always have a label to it. I think that it is something we as providers can do a better job acknowledging that we are asking you to do a lot of things that can contribute to stress.
For example, if we asked you to check your blood sugar before each meal, there are multiple steps:
- You have to wash your hands or maybe you are using an alcohol pad.
- You have to get a lancet or lancing device, the glucometer, test strip.
- You have to make sure you line everything up in the right way.
- Then you have to make a decision off of that number.
That is one thing that we are asking you to do, and we ask you to do it multiple times. Being stressed in relation to doing some of those tasks is perfectly reasonable. It is estimated that people with diabetes can spend upwards of four to five hours a day engaging in self-care activities. It is natural that it can be overwhelming. I think the numbers do not always reflect what everyone is experiencing, because we are not always screening for it. If we do not screen for it, you as a patient have to have the skill and the ability to say, this is a lot and this is stressful for me.
RK: That is a lot of time for someone to spend managing a chronic disease such as diabetes at home, four to five hours a day. You can see how it can place stress or additional burden on the person living with the disease. As you were talking, I heard you talk about things such as stress, and it almost seemed like feeling overwhelmed as well. Is diabetes distress an umbrella term for having those feelings or, is what we are talking about here, really that feeling of being stressed and overwhelmed with having a disease such as diabetes?
KL: It is specific to diabetes as a diagnosis. That feeling of stress and overwhelm is related to your diagnosis of diabetes, but it definitely encompasses varying levels. That is where we mentioned diabetes burnout — as that stress accumulates and maybe gets worse and is harder to manage, that is where you can see that burnout occur.
RK: It sounds like identifying diabetes distress is important to prevent it from eventually progressing to burnout. Is that right?
KL: Yes, I think it is a very important step because we can always get overwhelmed at times. I also think that knowledge is power. Looking at how you are managing your diabetes, there may be ways that we can make it easier for you, to prevent that accumulation of stress related to the disease.
RK: While we are talking about that, I wonder if you could go into a little bit more detail and how would someone know if they are having diabetes distress? How would a healthcare provider screen for it? Are there certain signs or symptoms or ways that an individual with diabetes could know if they are experiencing this?
KL: There are some validated scales that providers can use. One is called the Diabetes Distress Scale, and the Problem Areas In Diabetes (PAID) scale, and those both identify symptoms of diabetes as well as aiming to help identify what the root cause of the distress is. But it can also often be identified by reported symptoms. Some of these symptoms could be overwhelming thoughts about your food choices or worrying about having a low blood sugar. You might be disappointed that you are not getting the support from your provider or from your family members, and so those are some of the symptoms. You could also self-administer the scale online; it is available online for free. If you notice some of these symptoms or maybe there’s a change to your normal routine and you’re noticing high blood sugar, that could be an opportunity to step back and reflect if any of those emotions or experiences are applicable to how you’re feeling.
RK: That is great to hear about the different scales that might be available, but also the different symptoms and signs that someone could be aware of. Are there certain time-points in a lifetime of having diabetes that someone is more likely to experience diabetes distress. Is it more common when people are diagnosed, when there is a major life event or change in regimen? Or it just occurs anytime. What would you say?
KL: You are exactly right. You are more likely to experience signs of diabetes distress at diagnosis, and at times where maybe you have had a change in your regimen — something is new or maybe you were taking, one pill a day and now we have asked you to add insulin.
That creates a lot more steps and a lot more self-care tasks that we are asking you to engage in. Other times you may be more at risk for distress if you have had recent low blood sugar, as well as if you have any complications such as retinopathy or problems with your vision. A lack of family support can also be a risk factor that can contribute to more likely developing diabetes distress at that time.
RK: That is good to know, especially around times when we might have changes in therapeutic regimen, like you said, going from pills to insulin, for instance, or change in a support system that this could be a time when an individual could be more likely to experience distress. Just being aware of that and being educated about that seems like it is very important.
We talk a lot about these other psychosocial conditions associated with diabetes; depression and anxiety, which are also really important to identify, but we do not often talk about diabetes distress and burnout in that same conversation. Do you think we should be talking about it more? How are the conditions we are talking about today, distress and burnout, different from those medical conditions, anxiety and depression?
KL: I think that is a great question. First, yes, the symptoms can look similar between diabetes distress and depression or anxiety, some of the symptoms may overlap with diabetes distress. The emotional response varies. You may just experience one symptom, maybe lack of motivation towards diabetes tasks or fear of a complication versus depression and anxiety which have very specific criteria that need to be present for a certain period of time to meet a clinical diagnosis.
Now they can definitely coexist, you can have depression or anxiety as well as diabetes distress. Depending on what type of diabetes you have you can be anywhere from two to three times more likely to have a diagnosis of depression. I would say one, if you are not sure whether what you are experiencing is stress related to the illness specifically, or depression, that is when talking with your healthcare provider can be beneficial.
Then to the other question, yes, I think it is something that we should be screening for more and something that we should be having conversations with your patients. I personally like to start off my visits by asking, “What is your main goal for today? “and “What about diabetes right now is hard for you?” By asking those two questions, I think we get at what is making this stress build up and it helps us focus and identify what is important to you and what matters most.
RK: That is so important to hear what you are describing. I really like how you approach that to ask, “What is really troublesome for you right now?” or “What challenges are you encountering?” Do you find in your practice that individuals are hesitant to share the difficulties they are experiencing? Is this in any way, a reflection of the ability to cope with the disease or what do you tell your patients who may feel like “I should have this under check. Why don’t I have a better feel on this? Is this normal to experience?”
KL: Yes, it is normal to have these feelings, and I often encounter patients that do put self-blame on themselves. I think it is an important point to take a step back and say, you are not responsible for your diagnosis of diabetes. There is a huge genetic component when it comes to diabetes. You can have lifestyle factors to help manage your diabetes, but there is no moral failing, there is no lack of care. When you have a chronic illness we know that you want to feel good — no one wants to feel bad, no one wants to have complications, no one wants to have bad glucose numbers, so we definitely acknowledge that. I think that is something that we can do a better job, as providers, of reminding patients that it is not your fault that you have diabetes, and it is not your fault that it is not going well. There are so many things that can influence your blood sugar and not all of that is in our control. You can do the same thing day to day and one day have a great blood sugar number, and then the next day, your blood sugar decides to be high or it decides to be low. You know it is really about building those tools to address that.
RK: Well thanks so much for bringing that up because I think that aspect of self-blame can sometimes underlie the hesitation that individuals might feel before bringing forth challenges they are facing or obstacles that they see ahead. I think one of the time points where sometimes I see this in my practice is at the time when people need insulin. One of the things that we remind individuals is that this is a natural part of the progression of the disease. It doesn’t reflect in any way that the management was not optimal or that there was anything that the person with diabetes did that led to this. But having to take injections is more a reflection of the natural history of the disease than a failure to manage it.
I think that in any chronic disease, particularly one such as diabetes, where there is such a large aspect of self-management. It is important to keep that in mind, so thank you for bringing that up.
Since we’ve talked about, different ways that diabetes distress can present and how people can identify whether they may be at risk or not? Once, once it is identified that someone may have diabetes distress or experiencing feelings that are consistent with distress or burnout, what can they do? What would you recommend and how effective are the approaches that you usually recommend to reduce distress?
KL: I think stress is managed by building resiliency and that resiliency is the ability to find strength and seek support. I tend to encourage patients to identify things that you’re doing well. Maybe you never monitored your blood sugar before, now you’re checking it once a week or twice a week and that in itself is a win. That is a strength and a sign of resiliency.
Focusing on those small wins is important because each win is going to help you manage your diabetes and feel better doing it. Different lifestyle factors like adequate sleep and nutrition, engaging in activities that you enjoy, such as yoga or music those can act as a buffer to stress and also build resiliency. I think another place to start is identifying what matters most to you as a person and as a person living with diabetes. Maybe one of your biggest hobbies is trying new restaurants or you want to play with your kids more. All of that is an important part of identifying what the next steps are in your management and what steps we need to take together as a team to accomplish that goal. It is important when we are creating those goals that they are unique to you and are realistically able to be achieved.
When I sit down with my patients, especially those who are going through stressful times, I like to use the acronym SMART (Specific, Measurable, Achievable, Relevant, and Time-bound). So, we work on SMART goals. We create something that is specific, something that we can measure so that we know that we are actually achieving it. Something that is attainable and something that is realistic, and then time bound. We will say, “In the next month, I want you to go from checking your blood sugar once a week to checking it twice a week,” and I am not going to ask you to go from once a week to three times a day because that is not attainable, it is not realistic. Also, maybe that doesn’t matter as much to you. I think that is a good way to approach the goals.
Once we have that goal, I ask you “How confident you are that you’re going to make this change on a scale of one to ten,” and if the number is low and you are not confident, that tells me that the goal is not right. We need to take a step back and then reevaluate what our goal is. Then the last thing I would say in relation to that, is looking into connecting with diabetes education group classes or support groups. That can be either online or local, and the chances are you are going to find someone that has a similar struggle to you, or maybe they have been through that before, and they have a solution that has worked for them that may also work for you.
RK: Those sound like great resources and I like the idea of small steps celebrating small wins because over time those can become huge wins. And not only the resources in the healthcare team, but the support group that you mentioned, learning from others who are experiencing similar challenges and may in some ways be able to offer even more support because they are experiencing what you are going through as at the same time.
For the caregiver who has a loved one who is experiencing diabetes distress or burnout, I can imagine it could be challenging at times to know what is the best way to help alleviate the feelings or the distress that the person with diabetes is going through. What would you suggest that caregivers do or need to be educated about to best support the person living with diabetes who might be at risk for undergoing distress?
KL: I think the first thing is looking out for signs — is your loved one disengaging in some of the behaviors that they usually do to manage their diabetes? Such as, skipping medications, not checking their blood sugar, missing appointments. Then really having an open conversation and listening to your loved one to see if they are expressing that they are stressed. Or do they usually share information about their diabetes journey, or how you can help them, and then now they are taking a step back and not willing to share as much information. That may be related to some shame or guilt that comes from the diagnosis of diabetes.
The biggest thing that you can do as a caregiver is offering to listen. Offering support in the way that’s important to your loved one. Asking a question about “How can I help you or will it be helpful if I do X?” You can start with an open-ended question and then you can move to something specific. If they identify that one of their stressors is ,for example, picking out what to eat for their blood sugar. Then offer, “Can I cook dinner?” or “Can I plan the meals for this week?” Allowing them to take a break from the diabetes relationship with food, maybe the relationship with counting carbohydrates, and allowing you to take some of that burden as a caregiver.
RK: I appreciate you going over that because I think that sometimes it could be hard not only as a healthcare professional, but as a caregiver to know how best to support the individual who is experiencing the distress. Having those questions and having those ways to relieve, temporarily, some of the burden during times where there might be more stress could be immensely helpful, in terms of health outcomes and also just self-management.
KL: I think a good reminder to someone that’s trying to provide support is that support never has to be perfect. I think sometimes we get overwhelmed as a caregiver or as a provider saying, “I want to have the perfect answer.” We do not always have to have the perfect answer or the perfect solution to help you. Just by being present and offering, you as a person, to help can really be encouraging and helpful to the person that is going through this stress.
RK: Katie, thank you so much for talking about something we know it needs to be talked about more and really bringing attention to the importance of being educated on diabetes distress, knowing the signs, knowing the symptoms, knowing the resources that are available, and knowing what can be done both from a healthcare team and a caregiver perspective to help alleviate the distress that an individual with diabetes may experience in order to prevent burnout and prevent impairment in the ability to self-manage the disease at home for people.
For people who may be experiencing these symptoms, but have not had anyone ever ask them about it or pay attention to it, what would you say to them in terms of how they can go about seeking further counseling or further treatment or support for diabetes distress?
KL: One thing I will say is the fact that you are actually listening to this podcast right now is a great sign. That is a sign of resiliency and that you are acknowledging that maybe you or someone that you love is going through this stress. I think first you have already taken a great step towards managing that. The next step with bringing it up with your healthcare provider, I think if you have a relationship with maybe the nurse, medical assistant or support staff it could be helpful to mention it at the beginning of your visit that this is something you want to discuss with the provider.
If you don’t have that relationship with them when you go into your visit, I would suggest saying, at the beginning of the visit, “I do want to acknowledge that, I have been feeling overwhelmed and stressed lately. I think it might be related to how I am managing my diabetes.” Or you can ask your provider if you can talk about some of the things about your diabetes that is frustrating — share specifics. Let them know that this is the most difficult part about diabetes — maybe it is not checking my blood sugar, but maybe it is actually coming to the appointments. It can also interfere with other things in your life. You could say, ”I’m having a hard time concentrating at work, and I think it is because I am focused on, what to choose for lunch or how to take my medication.”
Then ask directly for support or guidance. So “I would love to talk about ways to manage my stress around diabetes better. What resources do you recommend?” Then just to give you an idea of what resources are usually recommended — just because you have diabetes distress does not mean that you need to see a mental health professional. It is often managed through diabetes self-management training or DSMT. It has been shown to decrease diabetes related stress and improve quality of life. Another thing that has shown improvements in quality of life is using a continuous glucose monitor (CGM) because it takes away some 25 of the daily tasks that you have to do. If you do have a comorbid condition like depression, anxiety, or there’s concern that maybe you need additional skills or services, you may get a referral to a mental health professional. But initially, usually management is going to start with the diabetes education.
RK: Thank you so much, Katie, for sharing all your great experience and expertise and for really bringing to light the aspects of diabetes distress and burnout that we should all pay attention to. This has been such an informative podcast and I’m sure our listeners have learned a lot as well. Thank you so much for being here.
KL: Thank you so much for having me. I appreciate it.
RK: I am Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit hopkinsdiabetesinfo.org.
We love to hear from our listeners. The email address is hopkinsdiabetesinfo@jhmi.edu.
Thanks for listening. Be well and see you next time.
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- Home - | - Episode 49: Diabetes and AgingIn Episode 49, Dr. Kalyani welcomes Dr. Scott Pilla, who will speak with us about diabetes and aging. Dr. Pilla is an assistant professor of medicine in the division of General Internal Medicine at Johns Hopkins. He completed his MD at Records Robert Wood Johnson Medical School, and his residency at Johns Hopkins Bayview. He also completed his clinical investigation fellowship in general internal medicine at the Johns Hopkins Hospital. Dr. Pilla is a practicing general internist with research on the management of type two diabetes and aging with a focus on individualizing diabetes treatment to account for the preferences and needs of older adults.
Download TranscriptTranscript: Podcast 49: Diabetes and AgingPodcast 49: Diabetes and Aging
Dr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani, at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.
Today we are thrilled to welcome Dr. Scott Pilla, who will speak with us about diabetes and aging. Dr. Pilla is an assistant professor of medicine in the division of General Internal Medicine at Johns Hopkins. He completed his Doctor of Medicine (MD) degree at Rutgers Robert Wood Johnson Medical School, and his residency at Johns Hopkins Bayview.
He also completed his clinical investigation fellowship in general internal medicine at the Johns Hopkins Hospital. Dr. Pilla is a practicing general internist with research on the management of type 2 diabetes and aging with a focus on individualizing diabetes treatment to account for the preferences and needs of older adults.
Welcome Dr. Pilla.
Scott Pilla, MD, MHS: Great to be here.
RK: We are so glad to have you here. This is a topic, diabetes in older adults, that we know will become increasingly more important as the population ages both in the United States and around the world. I was wondering if you could, first off, talk to us about why it is important to talk about diabetes and aging. What is it that makes this population unique that we need to address today?
SP: That is a great place to start. The first thing I think about is just how common diabetes is in older people. It is up to about one-third of older adults in the United States who have diabetes, so the prevalence of it is very high.
But what makes it both interesting and challenging is how heterogeneous it is, by which I mean how different people with diabetes are, who are aging, and how it impacts their lives differently. One of the things that we are still trying to understand about diabetes and aging is why some people get diabetes as older adults and are able to control it very well, and it doesn’t impact their life very much, while other people go on to have a lot of serious complications from diabetes, and it affects them quite dramatically. Those differences are an important place to start and an important thing to understand, both as a doctor treating older adults with diabetes and as a patient.
RK: It is really interesting. A few of the things that you mentioned are the heterogeneity of the population, which I think we’ll get to probably later in our discussion. You also mentioned that diabetes is more common in older adults. I wonder if you could maybe share with us some of the epidemiology and maybe give us some insights into why that might be.
SP: Diabetes really is a disease of aging because it gets more and more common the older that you get. It is unusual to have diabetes, type 2 diabetes at least, as a younger person—although we are seeing that because of issues with the obesity epidemic becoming more prevalent, younger people are getting diabetes as well.
But there’s something about the physiology of how your body regulates blood sugar: you just lose the ability to keep it under as good control the older that you get. As I was mentioning before, a lot of the time this manifests as a very slow progression from normal blood sugar to mildly elevated blood sugar that we call pre-diabetes to diabetes. This slow process is something that is often picked up by doctors and taken good care of, but occasionally, we get people who progress to diabetes very quickly. We are still trying to understand how that works.
In general, the epidemiology of diabetes is that the older you are, the higher your risk of diabetes. As I mentioned, up to about one third of older people actually have diabetes—this is part of the way that diabetes manifests with age.
RK: Wow, one-third—so one in three older adults. We did not define what we mean by older adults here, but what would you consider it? I know there are multiple ages you could use; when we are talking about these statistics, what is the age that is usually used?
SP: For these statistics, it is usually a cutoff of about age 65. Again, that is a very important point of complexity because we know when you turn 65, your body does not just suddenly change. Someone who is 65 may be very different from someone else who’s 65. If you are very active and you have good function and you are keeping up with your health, you can be as healthy as you were back in your fifties. That does not apply to everybody, unfortunately.
RK: I agree it is a nuanced discussion, but commonly it sounds like 65 and over. So one in three adults are living with diabetes over the age of 65. What about pre-diabetes? Is that also more common in the older adult population?
SP: Yeah, it really is as well. We see the whole spectrum of blood sugar get shifted up as you get older. So pre-diabetes is mildly elevated blood sugar. We define it typically based on this measure called the hemoglobin A1C level, which I know all of our diabetes researchers are very familiar with. But for people listening to the podcast who aren’t familiar with that level:
5.7 to 6.4 means you have pre-diabetes.
6.5 and higher means you have diabetes.
That level, 5.7 to 6.4, is a very complicated discussion of exactly what that means when older adults go into that pre-diabetes range. The epidemiology of it is that it is extremely common. If we combine diabetes and pre-diabetes together, the majority of older adults have one or the other.
RK: It sounds like if you put pre-diabetes and diabetes together, it is something like three out of four older adults have some form of glucose abnormality. That’s huge; that’s a high number.
SP: When you think about it that way, it is the minority of people who have normal glucose when they are older.
RK: That’s right. We have talked a little bit in the past about insulin resistance, and not to go into too much detail here, but I was just curious: since we do see so much pre-diabetes and diabetes in older adults, with this idea of insulin resistance, is this related to having more insulin resistance as people get older?
SP: I am going to be honest; I don’t know exactly how that physiology changes between when younger adults get diabetes and when older adults get diabetes. Generally, when we think about how diabetes develops, the first thing that happens is insulin resistance. The first change you could measure from normal is that the body needs to release more insulin to keep the blood sugar normal. Then as it progresses, the body is not able to release enough insulin to keep up with that resistance, and then the blood sugar starts to rise. That usually occurs over a period of years to decades. But I’m not sure whether that transition happens differently in older people versus younger people.
RK: Yeah, I think with the progression from pre-diabetes to diabetes, there have been various studies suggesting that that progression might be different in older adults; perhaps they can flip back to normal glucose status. I know in some of the work that we have come across that insulin resistance does seem to be more common in older adults, whether that’s with inflammation or just the body composition changes and hormonal changes that occur with aging. It is an interesting topic for another time, but there do seem potentially to be physiological reasons, perhaps with aging, why individuals might be more likely to have pre-diabetes or diabetes.
You talked about the age of diagnosis, and I thought it was an important point you made that we are seeing more type 2 diabetes in younger adults, but really diabetes is a disease of aging. That heterogeneity you talked about—the age by which people get diagnosed—is there a difference when people get diagnosed, let’s say in midlife versus in older age, in terms of their complication risk? Why the difference? Why the heterogeneity?
SP: There are some important points there. When I’m seeing people with diabetes, I put people into a much higher risk category when they have diabetes at a younger age because, for one, they are going to be living with high blood sugar for much longer. We know the way that blood sugar damages your blood vessels and your heart and your kidneys is—year after year—causing slowly accumulating damage. So when you are diagnosed with diabetes earlier, there is much more time for that to happen, and, at the same time, there is much more of an opportunity to prevent those complications because you have a longer time to intervene. I think the other thing about people who get diabetes at an earlier age is that I do worry. We do see a lot of people who have more severe diabetes related to other severe metabolic problems. Being overweight or obese, having really high cholesterol, or having other things that are related to your metabolic risk and your risk of outcomes like heart disease. If we look epidemiologically, people who get diabetes at an earlier age are much more likely to develop complications of diabetes. Whereas people who get diabetes when they’re older, especially those who have pre-diabetes or early stages of diabetes, their risk of complications can be almost as low as people who don’t have diabetes. That reflects the physiology that we understand.
RK: That is so interesting and it makes sense that the longer you have the disease, the higher the risk of complications and this just reemphasizes the importance of prevention, which I know we’ll talk about later too. Since we are talking about complications, could you talk to us a little bit about the complications that we see with diabetes and what are some of the unique considerations or other conditions that can occur with diabetes and aging?
SP: When we think about complications of diabetes, think about the different organ systems that high blood sugar can start to damage. We usually break it down into 2 categories. The first is macrovascular, meaning damage to large blood vessels; here we see the large blood vessels are feeding things like the heart muscle. So, you can get the risk of heart disease, heart attacks and heart failure, which is a weakening of the heart muscle. You could also get damage to large blood vessels in the legs, causing decreased blood flow in the legs or feet which sometimes, in severe cases, can result in foot damage and lead to amputations and those very severe complications of diabetes.
Then the other category is microvascular damage; there is damage to small blood vessels. Small blood vessels are in a lot of different places, but the organs that diabetes affects the most often are the eyes where you can get diabetic retinopathy — damage to the retina of the eye from decreased blood flow there, and that in the most severe cases, can lead to blindness. Then we have nephropathy, which is damage to the blood vessels in the kidneys. Again, this usually starts slowly, but if it is untreated it can progress to needing dialysis or end stage renal disease. Then the last is the nerves, the nerves in the body are also fed by small blood vessels. If diabetes starts to affect them it can cause neuropathy, meaning people start having changes in their sensation, usually in their hands or feet; pins and needles. That can also predispose people to having more damage to your hands or feet because of inability to feel when that damage is happening.
Those are the general complications of diabetes and how they arise. You asked about differences between younger people and older people in those complications? When I think about those, I think about what the challenges are that old people face in terms of their physical and cognitive functions. I think diabetes feeds into that because all of those changes that can happen as a result of high blood sugar can interact with the functional changes that are also happening as people get older. If, for example, someone is having difficulty walking because of arthritis and then, on top of that, they get changes in their sensation in their feet because of diabetes, it can worsen their function. We know that diabetes can be a major source of disability in older people. I try and put all of these potential complications of diabetes into the context of what is already happening with aging that is affecting someone’s health and function. There are so many different ways that can interact there.
RK: It certainly seems like there are many different things to think about. You mentioned the microvascular and macrovascular complications; the complications we think of for people of any age are heart disease, stroke, eye disease, nerve disease, and kidney disease. It sounds like with a longer duration of disease, people might be more likely without optimal management to have those complications. Are those complications more common in older adults? Is there a higher prevalence of those complications among older adults?
SP: Yes, they are more common in older adults, both with and without diabetes. Your blood vessels aren’t as strong as you get older, and they get narrowed from a lot of reasons, like high cholesterol and high blood pressure, and just living with them for decades and decades. However, people with diabetes have, higher rates of these complications. Although, as we talked about earlier, when you get diabetes, especially early diabetes as an older adult, your rates of these complications don’t go up by that much. Especially compared to people who got diabetes when they’re younger who really are, at the highest risk of these. So the people who’ve been, who are older adults who’ve been living with diabetes already for decades, they are the people who are at the highest risk.
RK: That makes sense—that if they have had the disease for longer periods of time, they would be at greater risk as an older adult. You also mentioned, which I think is an important point for us to talk more about, these other conditions that can occur more commonly in people with diabetes as they age—what might be called geriatric syndromes. I wonder if you could talk a little bit more about those and how common they are in people with diabetes and why it is important to recognize them.
SP: What we call geriatric syndromes are basically issues and health conditions that kind of frequently impact older adults and are common sources of disability in older adults. Diabetes, I would say, affects the vast majority of them (geriatric syndromes) and makes the vast majority of them more likely to happen. Again, every older adult is very different, so which of these syndromes affects different people is variable. Some of the ones that I think of commonly are changes in thinking and cognition—as your brain ages, often people develop decreased memory or dementia—and diabetes does make that more common.
One of the things that I research is hypoglycemia (low blood sugar), and diabetes treatments, which cause low blood sugar, can also make people have issues with their thinking. That can be another way that it is not just the diabetes itself impacting how people think and function as they get older; it is the effects of the treatment.
A lot of the other geriatric syndromes are different ways that the body is no longer functioning at its full capacity and causing limitations in what people can do. I know one area of your research, Dr. Kalyani, is about frailty and loss of physical function and strength as people get older. We could see that definitely impacts diabetes, in that diabetes makes that happen more often. It could also, I think, have a bidirectional effect where frailty makes people be able to exercise less and get around less, and then they are really not able to keep their blood sugar as well controlled because they are not moving as much.
Then another one that I will mention with geriatric syndromes is musculoskeletal issues like arthritis in the hands, where, on one hand, diabetes does not necessarily cause this, but when it happens, it can make people have difficulty taking care of their diabetes because they have difficulty checking their own blood sugar or administering insulin or doing the kind of fine motor skills that are required for a lot of these diabetes self-management efforts.
RK: I think that there are just so many different types of syndromes that are conditions that can occur more commonly in older adults. Part of the challenge is that there are so many of them, and I appreciate that you highlighted perhaps some of the ones that we may be more familiar with or may have a greater impact on day-to-day quality of life for older adults. I think that as people age, something that becomes more and more important is the ability to do tasks at home, to have mobility, to have intact cognition, and to be able to self-manage. I appreciate you going through all those different syndromes.
One of the ones you talked about was cognitive impairment, and I think that we are hearing more and more about that in the general population, but perhaps it would be worth talking about why cognitive impairment and dementia are so important to keep in mind for people with diabetes. What is the connection there?
SP: One question is how does diabetes contribute to cognitive impairment? That is a complicated physiologic question that I think people are still trying to figure out. One of the complexities, as I mentioned, is that diabetes itself can increase your risk rate of developing cognitive impairment, probably through its effects on the blood vessels in the brain, but also having cognitive impairment makes it more difficult to control your diabetes and to treat your diabetes safely. So that is something that we see also very commonly: that people who have cognitive impairment or dementia have more risks from diabetes treatment, like more side effects and more issues with hypoglycemia, or low blood sugar. It can be more difficult to get their blood sugar under control safely. That is one of the reasons why I assess cognitive impairment very frequently in people with diabetes, and I really think about, “Is the treatment that I’m giving them safe, and can they manage it?” When I think about managing it, not just them, but their whole system of care partners and care structure, I know everybody around them who is helping them take care of their diabetes—do they have the support that they need to do it safely?
RK: Yeah, I do think that’s where it becomes important, especially for our older adults who may not have that support, whether it be family support or caregiver support, that having some of these geriatric syndromes, particularly cognitive impairment or dementia, can make self-management more difficult. Isn’t that true?
SP: Yes, this is so true. There are ways of trying to get around that, but for the most part, it is just going to be altogether more difficult. This is something that people with diabetes and their care partners just struggle with. Unfortunately, there is no great way of making it easier.
RK: You also mentioned muscle loss, or sarcopenia, and this is an area that I have dedicated a lot of time to understanding more. This is something that we see with our older adults as well as in the general population: that they can lose muscle as they age, but in people with diabetes they can lose muscle faster than their counterparts. As you mentioned, the implications on mobility and being able to move around and the other body composition changes that occur with aging as well; people tend to retain more fat tissue, and that might also relate to some more of the insulin resistance we see with aging.
It is complicated with all of these different conditions that we can see, but it is important to recognize because of the impact it can have on self-management and quality of life. Just to summarize some of the other ones, urinary incontinence is something we talk about as well. We will talk a little bit about hypoglycemia in a little bit too. But there are things that can occur more commonly, like frailty, as well in older adults with diabetes.
As an internist yourself, how often do you screen for these syndromes in your older adults with diabetes, or how should someone who might have a loved one who’s older with diabetes or might be over the age of 65 themselves find out more if they might be at risk for these geriatric syndromes?
SP: It is a good question, and I think it is something that internists struggle with because there are just so many ways that your body changes as you get older and so many ways that diabetes could impact that. It is hard to know; you obviously cannot ask for every single one in every visit. I think what it comes down to is, as an internist, knowing your patients well, and as a patient, being able to bring issues that develop to your doctor’s attention openly. I always encourage patients that if they are having changes that they notice, we should talk about it early because it might be an effect of diabetes, and it might be something that we could address if we know about it early.
I will mention hypoglycemia again, but one of my studies about hypoglycemia, which is a complication of diabetes treatment, shows that only about a third of people who should be discussing hypoglycemia have actually discussed it in their visit with their doctors. Sometimes people may feel these things are either like a fault of their own or something they maybe do not want to burden their doctor with, but I think it is important to really bring these things up.
In terms of what doctors can do, I think there are certain things that, if caught early, are obviously very important and should be regularly screened for in visits or asked about whether or not the patient brings them up. One of those things is cognitive impairment. We should know when our patients are having changes in their thinking, and there are tools that we can use in clinic to do that efficiently. Then for people who are on these higher-risk medications for diabetes, I think we really should be screening for their side effects to make sure that we understand the risks that the medications are having.
RK: I agree; I think it is important for healthcare providers to keep this at the top of their mind. Also, as an individual who might have diabetes, to be aware that this can happen, to be aware of symptoms, and then to talk to your healthcare provider about whether you should be screened for these conditions.
We talked about hypoglycemia, and I think this is a good place perhaps for us to talk a little bit more about that because it is one of those conditions that can occur as a side effect or complication, or however you want to describe it. But when it does occur in people with diabetes, it can be potentially serious depending on how quickly it is treated and how severe it is. It is worth it for us to talk a little bit more about how we define hypoglycemia and what the symptoms are, if you could share some insights.
SP: Hypoglycemia has pretty specific definitions. The general definition of hypoglycemia is having a blood sugar level that is less than 70 milligrams per deciliter (mg/dL). That would be on a finger-stick reading of blood sugar. If you are less than 70 mg/dL, you are considered to have hypoglycemia, but within that there is really a wide spectrum. We categorize it according to levels.
Level one hypoglycemia is having a blood sugar in the 54 to 70 mg/dL range, which is low, but usually not so low that it can cause really serious harm. But then less than 54 mg/dL, we call level two hypoglycemia, and this is when you know people really can suffer a lot of serious consequences, which we will talk about in a second. Level three hypoglycemia is any low blood sugar level that actually changes your thinking and consciousness and sometimes can wind people up in the emergency room or needing assistance from somebody else. If you need help to manage a hypoglycemic episode, that is considered level three hypoglycemia, the most severe stage.
You mentioned symptoms, and symptoms of hypoglycemia are tricky because they are fairly varied and can occur due to other conditions outside of hypoglycemia. The most common symptoms that people feel are this sense of getting revved up; it is an adrenergic reaction, people can have like rapid heartbeat and sweating, sometimes it comes with headache and anxiety. Those are what we call the adrenergic symptoms of hypoglycemia.
But then as it gets more severe, there is another category called neurocognitive symptoms of hypoglycemia, meaning that it is affecting how you are thinking and feeling. Those can be symptoms like feeling drowsy or confused or changes in your emotions and acting strange. The most severe, cases could be decreased arousal or coma. That is the natural progression of hypoglycemia symptoms. In that area not everybody experiences the symptoms equally.
People who have had diabetes for a long time or who have a lot of hypoglycemia can get something called impaired hypoglycemia awareness. This means that they do not experience the typical symptoms of hypoglycemia when their blood sugar is low. On one hand that sounds like it could be good because, “Oh, I’m not having as many symptoms,” but the problem with that is you do not get the early warning signs. These early symptoms that you have when your blood sugar is just starting to get low, they just sail right through that, and then the first thing that hits them is more severe symptoms. Because they do not have this warning, it could cause really serious hypoglycemia more often.
RK: Thanks so much for going into detail and sharing that really important point, that older adults may not have these early symptoms of hypoglycemia, or low blood glucose, just as part of the process of aging. They might not have that racing heart rate or sweatiness until it becomes more severe. It does behoove us to talk about monitoring for low blood sugar even more for older adults. Would you say that it’s even more important in older adults, or what do you tell your patients with diabetes?
SP: I definitely think it is more important, both for the reason you mentioned that some people will not have those early warning symptoms and that we know that the risk of having more severe hypoglycemia goes up as you get older. The thing that we did not mention yet is that most diabetes medications do not cause hypoglycemia, at least by themselves; really, the most risky medication for hypoglycemia is insulin, especially like multiple daily insulin or the rapid-acting insulin that people sometimes need. Then there is another class of medications called sulfonylureas that are an older class of medications but are still very commonly used in older people. They also cause hypoglycemia without needing to be on insulin. The other diabetes medications, if you’re just on a medication like metformin or one of the newer medications by themselves, would not be expected to cause any significant hypoglycemia. When we talk about monitoring, it really depends on what your risk is and what medications you’re on.
RK: That is a great segue into talking about medications for diabetes and those that might have a higher risk for hypoglycemia versus those that might be relatively safer to use with older adults who have diabetes. I guess one of the questions that I often get, and I think it would be great for you to address, is, “Is insulin safe for older adults with diabetes?” We know that insulin has a side effect of hypoglycemia. We know, unfortunately, that it’s one of the reasons that people come to the emergency room. It’s one of the top three reasons, in fact, for having hypoglycemia and using insulin. We know that there are safe ways to use it as well. I wonder if you could talk to us about what medications, if any, people who have diabetes and are older should avoid and how safe it is to use medication such as insulin.
SP: Medication selection with aging is a very important topic and very complex. I will say, my general thought about it is, all of these medications have their place, and they may be the right medication for someone in certain circumstances. I try and use the medication that has the lowest risk but the greatest benefit for any particular person. Insulin for older people with type 2 diabetes is often used in two circumstances: one is where they cannot use other medications because of side effects or because of contraindications like low kidney function. We just do not have a lot of medication options, so insulin can sometimes be the only one that will work. Then insulin is often used when people have had diabetes for a long time and their pancreas just is not making enough insulin on its own anymore. Sometimes insulin is the only way to keep the blood sugar under control at that point. I think insulin has its place and is an important medication for older people. That being said, if those two circumstances are not happening, I try to use insulin as little as possible because I am very aware that it is the most risky medication for an older person to be on, bar none. If you really do not need it, I do not want you to be on it, and I want us to explore other medication choices.
RK: I think it is important that it depends on what it is being used for, and for many individuals with type 2 diabetes, they will need insulin eventually just because they cannot produce any on their own—in that case, we really do not have any other choices. In situations such as you mentioned, where there might be other choices, and increasingly we are seeing other medications used that have lower hypoglycemia risk, those might be preferred for older adults who are more likely to have symptoms of low glucose or not have symptoms of low glucose as well.
In terms of types of insulin that can minimize hypoglycemia, I wonder if you want to talk a little bit about that too. Not all insulin is the same, and we do have options for insulin that can lower that risk too.
SP: Yes, that’s true. The most risky forms of insulin are the rapid-acting insulins, especially when people are using them on what is called a sliding scale—they are adjusting their insulin based on numbers. People have to be very careful with giving themselves the right amount of insulin. Sometimes it is hard to estimate exactly how much insulin you need. Sliding scale insulin is the most risky form, but it is also sometimes necessary if you need closer control of your carbohydrate intake.
The longer-acting insulins are less likely to cause hypoglycemia, and now there are newer formulations of these longer-acting insulins that act in the body very slowly and at a very steady state that have the lowest risk of hypoglycemia of any insulins that have come before them. I think that those are definitely options, those ultra-long-acting insulins that are being developed.
That being said, I think as much as the type of insulin, it is having it being dosed appropriately and also being aware of when that dosing needs to be changed. For example, a lot of people get in trouble with insulin when they get sick and they are not eating as well, and they do not know exactly what to do with their insulin because their blood sugar might be high, but their intake is low, and how do we manage that? We all know as you get older, you are more likely to get sick and have things happen—when those things happen, you need to be in close contact with your doctors to know exactly how to manage your insulin so that you do not get into trouble.
RK: It is exciting to have so many newer insulins, those longer-acting insulins, on the market that can reduce hypoglycemia. As you mentioned, those rapid-acting mealtime insulins really are designed to be used when you are eating. If they are not matched appropriately in dose or if you eat less, you could be at greater risk for hypoglycemia, or if you exercise more. All those lifestyle patterns also contribute, as you mentioned, to the risk of hypoglycemia. We have not yet talked about perhaps another class that we should briefly talk about, sulfonylureas, and their effects on lowering blood glucose. I wonder if you could just briefly talk about what that class is, maybe some common names people would be familiar with, and how those can be used safely in older adults.
SP: Sulfonylureas are oral medications, and the three most common ones have the generic names of glipizide, glyburide, and glimepiride. If you have been on one of those medications, that is a sulfonylurea. I think oftentimes people think of sulfonylureas as fairly benign because they don’t cause severe hypoglycemia that often and they work fairly reliably. When people take them, I think they have a very expected effect on lowering your blood sugar.
That being said, I wanted to tell a story about a patient I took care of when I was a resident that had a really bad complication from sulfonylureas that just really stuck with me. This patient was on glyburide, an older woman who had early stages of dementia and was taken care of by her daughter. She developed symptoms of a urinary tract infection and was brought to an urgent care center to get that treated. They, the urgent care, put the patient on Bactrim (trimethoprim/sulfamethoxazole), which is a common antibiotic that we use to treat urinary tract infections. The daughter left the home to do a few errands, and she came back, and she found her mother on the floor unconscious. The Emergency Medical Services (EMS) showed up, and her blood sugar was 40 mg/dl. They brought her to the hospital, and that is when I met her—I did her intake when she came into the hospital. We realized that what happened was that this medication, Bactrim (trimethoprim/sulfamethoxazole), interacts with sulfonylureas and actually causes their dose to be at least three times as high as it would be otherwise. That was enough to cause this person to have profound hypoglycemia, and she was treated quickly, and she recovered somewhat, but she was in the hospital for almost a week and was not back to her baseline by the time she went home. Her thinking was not nearly as good as it was before this happened; it was a very bad thing for this person.
So even though these medications are generally not considered to be that risky, there are certain circumstances where they can be very high risk. These interactions between sulfonylureas and antibiotics are something that I always like to talk about because doctors do not seem to be aware of this, and it is a very common problem.
RK: Thanks for sharing that story. It highlights the importance of educating people who are taking these medications on the risks that can occur, particularly with infection or not eating as much as usual. Also knowing when to reach out to your healthcare provider—when you might need to reduce a dose or stop a dose of medications at higher risk of hypoglycemia. I think that knowing that with these caveats, there are medications in the sulfonylurea class that might be longer acting and reduce the risk of hypoglycemia. Even extended-release versions of these can lower the risk of hypoglycemia. Knowing that they are inexpensive and really effective at lowering A1C means that we do use these, but we should be using these cautiously, especially in those at higher risk of hypoglycemia, as you mentioned.
SP: The patient education part of it is really important because if you prepare people and they know what the risks are and they know when they should be cautious, you can really improve how safe these medications are. As you mentioned, they are still used very commonly because they are effective and are quite cheap. It is not that they do not have a place; they might be the right medication for some people.
RK: So, we have not really talked about A1C or what glucose level people should aim for when they are older; part of that is because of this idea of individualized care. I wonder if you could talk a little bit about what patient-centered or individualized care looks like for older adults with diabetes. What are the A1C targets that are usually recommended for older adults?
SP: When I think about individualized care of diabetes, the first thing I think about is that every aspect of diabetes care should be individualized and should be targeted to what a person needs. One area of individualized care that has had a lot of discussion over the last two decades is: What should your blood sugar goals be? The reason that this is so important is that the lower you push your blood sugar down, the more you can lower complications of diabetes, but you also increase the risks of the medications and the risks of treatment. How to balance those benefits and risks changes as you get older. There is a very nice figure in the American Diabetes Association Standards of Care, which kind of shows how we should select those blood sugar goals for different people and different age ranges.
The general principle is that people who have a better chance to benefit from lower blood sugar should get lower goals, as in more aggressive goals. Then people who have a higher risk of having side effects from medications should have less aggressive goals. It is about balancing those things. Some of the specifics we think about are your age and function. For healthy, older adults who have good function and are generally doing well, we say your blood sugar target should basically be the same as for anyone of any age, which is a blood sugar range of an A1C around 7 to 7.5%.
This is where we set blood sugar targets generally and sometimes even lower targets for people who are very healthy or who have not had diabetes for very long. Then as you get older and have accumulated health problems or decreases in your function or your thinking, you really have less of a chance to benefit from having a lower blood sugar; you have more of a chance to get harmed. So as we mentioned earlier, having dementia, for example, really poses a higher risk of side effects from diabetes medications. For people who are in those categories, the A1C goal could be 8%, or it could be even higher than 8%, depending on where their health and function fall. But the key thing to think about is that doctors should not just set a goal of 7 to 7.5% for everybody. They really should think about “What is the goal that my patient needs, and how risky is it to get there?”
RK: That is really helpful to hear about how the A1C target really can slide or be individualized based on the individual’s health function, life expectancy, and other considerations. It sounds like it is a conversation that really needs to be had between the person with diabetes and their healthcare provider to determine what’s the best target for them.
We also have not yet talked about technology, and we know that there is a lot of new diabetes technology, which is really exciting. People of any age should be eligible and get coverage for these exciting new technologies. Are there considerations unique to older adults that we should keep in mind?
SP: I think the big new technology that everyone is talking about is continuous glucose monitoring (CGM), and that is what most people are thinking about when they think about diabetes technology. Technology is advancing in a lot of areas of diabetes, especially type 1 diabetes care when people have to be on insulin. Every year there are better automated insulin delivery systems and these smart devices that can match your insulin needs to your carbohydrate intake very closely. When we talk about older people, mainly with type 2 diabetes, continuous glucose monitoring has been gaining use and gaining evidence that it is really helpful.
The people who it is most helpful for are the people who are on insulin because we know that they need closer monitoring of their blood sugar to prevent hypoglycemia. Their blood sugar fluctuates more when they need insulin; being able to capture those fluctuations in real time on a CGM device can show you exactly what is happening in your body and allow you to react more quickly to changes. They also let you and your doctor learn more about what the patterns are in your blood sugar. You can see what you are doing and what makes highs, or when you have a hypoglycemia episode, what precipitated that, and what time of day they are occurring so that you could change your treatment and your strategies so that you could match your insulin to your needs very precisely.
I will mention that CGMs are a pretty complicated technology. They are getting easier and easier to use; most of the time you need to be able to connect a device to a smartphone, be able to navigate apps, and understand the numbers that go along with it. There is definitely a learning curve, and there are definitely technology portions of it that a lot of older people will not be as comfortable with. The devices are getting better and better every year, and they are getting easier to navigate and understand. I think they are becoming more and more accessible to older people.
RK: Yes, and it is so great to have these technologies available. I think there are so many aspects that can make it easier to facilitate day-to-day care, but perhaps for those who have cognitive impairment or physical limitations or dexterity limitations, there are continuous glucose monitors that might be voice activated, for instance, or have big screens that might make it easier for people with those limitations. Overall, it is a really exciting time for people of all ages.
SP: There are monitors that you can have a care partner or someone else have the data go to them too. If someone needs help with managing the data, someone else can be there to do it too.
RK: One aspect that I thought would be important for us to talk about is the role of the caregiver. This would be a great time to talk about that. For an older adult with diabetes, what is the role of the caregiver, and how could they be supportive to the individual with diabetes?
SP: I have seen my older people, especially those who are struggling with issues with cognition or with mobility, having somebody who can come with them to appointments and help in the management of the diabetes can be just so valuable. There is just so much to do and so much to keep track of that I think a lot of older people need help. Having more than one person involved in these management decisions can make everything go smoother and easier. What the roles are varies so much by individual and what they need. I will mention there are very specific ways that caregivers can get involved and help. One that I am very interested in is prevention of hypoglycemia. Hypoglycemia can be a burden to not just the person with diabetes but their caregivers as well, because it can be really stressful, especially if they are having these severe episodes that find them unconscious or confused and the caregiver has to be the one to address that. One of the ways that can improve the safety is having a caregiver be trained in the use of something called glucagon. Glucagon is a medication that is given either nasally or as a shot that can rapidly reverse hypoglycemia. Having that in the home and having a caregiver know how to use it can be a way of improving safety and taking the power back from these really severe issues that can wind people up in the Emergency Room (ER).
Aside from hypoglycemia and medication management. I think caregivers’ roles can be so varied. It could just be about getting people to appointments and helping them navigate the health system, to helping administer their medication safely, and/or helping them keep track of their blood sugar. There can be so many things a caregiver can do. As a doctor, I also think about the fact that caregivers have a lot of burdens on them too. They often have their own health problems and sometimes feel the need to sacrifice their own health to help their partners. I think doctors need to also be aware of what the care partners and caregivers are going through and what they are dealing with and not just say, “Oh, you have to do this and do this,” and just keep harping on it. You have to try and make it practical and easy and something that they can accomplish without overburdening themself.
RK: That’s so important, what you mentioned about not only the physical support but also the emotional support that caregivers can give. The education that is important for caregivers for hypoglycemia treatment, like you mentioned, is knowing what to do in cases of an emergency. I always enjoy having the caregiver when they come to patient visits. Having a caregiver or a family member who has an active role in the care plan, is just so critical, especially as individuals age and have greater needs. Thank you for going over that.
We have covered a lot today, and I really appreciate you talking about the different ways that an older adult with diabetes may be affected by complications and geriatric syndromes and also the unique considerations that we have to think about in management.
Just some parting words that you might have for our audience, for anyone who has, let’s say, a parent or a loved one or maybe even themselves who falls into this category of having diabetes in older age and maybe struggling to find a healthcare provider who understands their needs or really to understand why things may not be working for them the way they work for their younger individuals—what would you say to them in terms of things that they can do or next steps?
SP: What I would say about taking care of a relative or loved one with diabetes who is struggling is I would start by thinking and talking amongst yourselves about what the goals for diabetes are and what their priorities are because knowing what you want to get out of the medical visit is extremely important. Telling your doctor that it is extremely important so that you are all on the same page at the start of the visit and that the doctor understands what you are hoping to gain. Priorities are important too because you cannot always address everything in one visit with your doctor. So, you should think, “Okay, what is the most important thing, the most important problem to focus on today?” If you come to your doctor with that in an ordered list, it can be really helpful to set the expectations for the visit and make sure something is accomplished. I would also try and bring in the worries and fears that you or the person with diabetes have so that the doctors know what they’re worried about and if there’s a way to alleviate that, because I think doctors often don’t know when their patients are suffering emotionally or struggling emotionally with the disease. And understanding that can just really help frame what the doctor can do for you and help them understand you as a person.
I think those three things—talking about goals, setting priorities, and then bringing up your worries and concerns in a visit—will really help things move forward.
RK: Thanks so much, Dr. Pilla, for sharing those last words. Goal setting is so important, especially in the older adult population. I really appreciate you highlighting that and for all of the expertise and clinical insights you shared today—giving some insights on things for older adults with diabetes to be aware of, to ask their healthcare providers more about, and really to be prepared for so that they don’t run into issues and can live a long, healthy life with this condition. Thank you so much for being here. We really appreciate it.
SP: Great. Thank you for having me. It’s great talking about it.
RK: I am Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit hopkinsdiabetesinfo.org.
We love to hear from our listeners. The email address is hopkinsdiabetesinfo@jhmi.edu.
Thanks for listening. Be well and see you next time.
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- Home - | - Episode 48: Diabetes Technologies in the HospitalIn Episode 48, Dr. Kalyani welcomes Dr. Mihail “Misha” Zilbermint, who will speak with us about diabetes technologies in the hospital. Dr. Zilbermint is an associate professor of clinical medicine in the division of Endocrinology, diabetes and Metabolism at Johns Hopkins University School of Medicine. He is the Director of Endocrine Hospitalists at the Johns Hopkins Community Physicians Chief and Director of the Division of Endocrinology, diabetes and Metabolism at Suburban Hospital in Bethesda, and has pioneered the Endocrine Hospitalist Program at Johns Hopkins Medicine following the completion of his endocrine fellowship at the National Institutes of Health. His commitment to innovation has earned his specialized diabetes team, the Johns Hopkins Innovations and Clinical Care Award. Along with Dr. Zilbermint, we also welcome Jordan Spivak, who is the inpatient diabetes educator at Johns Hopkins, Sibley Memorial Hospital and Suburban Hospital. Jordan has seven years of experience as a registered dietician with clinical experience at Northwestern Medicine in Chicago, and now two and a half years at Johns Hopkins. She most recently graduated with her Master’s of Science in Clinical Nutrition from the University of Wisconsin Madison.
Download TranscriptTranscript: Podcast 48: Hospital Management of DiabetesDr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani, at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.
Today we are thrilled to welcome Mihail, also known as “Misha,” Zilbermint, who will speak with us about diabetes technologies in the hospital. Misha is an associate professor of clinical medicine in the division of Endocrinology, Diabetes, and Metabolism at Johns Hopkins University School of Medicine. He is the director of Endocrine Hospitalists at the Johns Hopkins Community Physicians; chief and director of the Division of Endocrinology, Diabetes, and Metabolism at Suburban Hospital in Bethesda; and has pioneered the Endocrine Hospitalist Program at Johns Hopkins Medicine following the completion of his endocrine fellowship at the National Institutes of Health. His commitment to innovation has earned his specialized diabetes team the Johns Hopkins Innovations and Clinical Care Award.
Along with Dr. Zilbermint, we also welcome Jordan Spivak, who is the inpatient diabetes educator at Johns Hopkins, Sibley Memorial Hospital, and Suburban Hospital. Jordan has seven years of experience as a registered dietician with clinical experience at Northwestern Medicine in Chicago and now two and a half years at Johns Hopkins. She most recently graduated with her Masters of Science in Clinical Nutrition from the University of Wisconsin–Madison.
Welcome, Misha and Jordan.
Mihail Zilbermint, MD: Thank you.
Jordan Spivak, RD, LDN: Thanks for having us.
RK: We are so excited to learn from you both today about the use of technology in the hospital setting. This may be something that people don’t think too much about, but as technology becomes more and more common to use at home, this becomes increasingly a question that I know I hear from my patients: “What do I do with my continuous glucose monitor or insulin pump in the hospital?” We are looking forward to having you both shed some light on that. I wonder if you could start by telling us: why is it important to discuss the use of technology in the hospital in the first place? How common is it?
MZ: Thank you, Rita. First of all, we have to acknowledge that diabetes is extremely common in hospitalized patients; about one in four hospital patients have diabetes. Managing blood sugar in a hospital is absolutely critical to prevent complications, to speed up recovery, and, of course, to improve our outcomes. The diabetes technologies transform diabetes care, but hospitals have been slower to adopt these tools compared to some of our outpatient colleagues.
In 2025, the American Diabetes Association standard of care now supported the continued use of continuous glucose monitors and insulin pumps in the hospital when it’s clinically appropriate. Of course, there is proper training, proper protocols, and confirmatory blood glucose checks.
JS: As you mentioned, Rita, so many patients that are hospitalized now are already using these continuous glucose monitors and insulin pumps at home. It really does make sense to explore whether they can be used safely in the hospital with where we’re at with technology.
I had a patient just a few days ago with type 1 diabetes that was on a CGM at home and had it removed right on admission. It makes sense to explore whether we can replace the sensor for the patient so that they can continue to be involved in their care and have that autonomy. Then furthermore, have it re-set up for them once they get home.
The pandemic also accelerated a lot of interest in remote glucose monitoring. Having nurses cluster their care in a room and being able to see the patient’s blood sugars without even having to go into the room. Now more hospitals are integrating those continuous glucose monitors into inpatient care.
RK: That is so interesting to hear you both talk about how much this has become a topic to address. You mentioned, Misha, that it has now entered our clinical practice guidelines, the use of technology in the hospital. I think that really does highlight the importance of the topic that we are talking about today.
Jordan, you mentioned the remote monitoring, and it does seem like the hospital setting would lend itself particularly well to the medical staff or the nursing staff being able to remotely monitor blood glucose metrics or other metrics from the technology patients are using in their hospital room. Exciting possibilities for ways that we can really improve and facilitate optimal patient care. When we talk about technology, what kinds of technology are we talking about? And can these be used safely in the hospital?
MZ: We know that, as I mentioned previously, the American Diabetes Association now supports the continued use of personal continuous glucose monitors, or CGMs, and also insulin pumps in the hospitals. But what is important here is we clearly need institutional protocols and point-of-care blood glucose confirmations, like finger sticks for insulin dosing and for hypoglycemia detection.
We know that insulin pumps are little tiny machines which can deliver insulin to a human, mostly to people who have diabetes. We call them automated insulin delivery systems—they can also be continued in the hospital when clinically appropriate, but it really depends on the staff training, availability of supplies, and the patient’s ability to manage the device.
That’s why here at Johns Hopkins, we spend a lot of time meeting with each other; all of the endocrinologists and the diabetes educators from all of the hospitals in Maryland and DC got together to put together a detailed policy in the training documents for the nursing staff to make sure that everyone knows what to do when the person walks into the hospital with either a continuous glucose monitor or an insulin pump.
JS: Just to piggyback off of what Misha said, so in our hospital we do allow patients to use their continuous glucose monitors when they’re admitted, as long as the traditional finger sticks are still being done by the nurses per our protocol. The continuous glucose monitors are not yet FDA approved for hospital-initiated use, meaning that hospitals can continue their personal continuous glucose monitors. We’re not putting on continuous glucose monitors and saying we’re using them by our hospital policy, but if the patient has one when they’re admitted, they can continue to use it. We do educate our nurses on that a lot when they’re oriented to the hospital and through my education on the units.
We do have a special program here where we can initiate a continuous glucose monitor at the time of discharge as long as the patient meets the predefined criteria. As long as the patient is alert and oriented, we double-check with their insurance coverage for continuous glucose monitors at the time of discharge. That is really just to set them up for success at that time when they get home and educate their family and things like that.
Hybrid monitoring protocols that combine the continuous glucose monitor readings and then those blood sugar checks done by the nurses is really, I think we are finding that is probably the safest approach.
MZ: I totally agree with Jordan. For example, we had a patient a few days ago who approached us saying that there is a clear discrepancy between a glucose reading on his personal monitor, his insulin pump, and the finger stick, which nurses are performing. We told him that sensor glucose levels and blood glucose levels are different; they are almost never identical. They are almost never the same because we are measuring slightly different things. I’m sure you discussed in your previous podcast the difference between blood glucose and sensor glucose levels. But what we do encourage all the time—every time a nurse comes in, if your sensor allows a calibration, which means that the patient has to manually enter the glucose number, we definitely encourage you to do it.
RK: Those are some really important points that you both brought up in terms of how we can, in practical terms, integrate technology into the management of a patient with diabetes in the hospital. I thought what you mentioned about nursing education really could not be overemphasized. While the person with diabetes has been using this technology, now that they’re in the hospital, it’s equally as important for the medical team to be familiar with the technology as well.
So much of what happens—and Jordan, I know you do a lot of it in the hospital—is diabetes education. All the technologies are different; all the continuous glucose monitors are different in terms of their features. It’s really important to understand how they’re used.
I just wanted to clarify a point that you made as well. It sounds like what you’re saying is that when people have continuous glucose monitors and if they’re able to continue them per hospital policy in the hospital, these don’t substitute for the glucose monitoring that the nursing staff would do. It would be a compliment. Is that right?
MZ: That is correct.
RK: It’s giving additional information that might otherwise be missed—how often would you say, otherwise, people get finger sticks in the hospital?
MZ: On average, most of the people get at least five finger sticks in the hospital. Some of them get six finger sticks in the hospital. If patients are very ill and they have to be admitted to the intensive care unit, when we have to get insulin directly for their IV line, sometimes we have to do it every hour. In the future, when CGM will be FDA approved to use in the hospital setting, I think we are looking forward to the time when we do not have to finger prick patients so often.
RK: That’s a really important point. What do you see as the benefit of continuing these technologies in the hospital? If we could just touch upon that briefly.
MZ: I believe that even though we don’t have an FDA approval, per se, to use them for insulin decision-making. But what I have found is that patients who use CGM, for example, patients who use CGM in the hospital, are becoming a little bit more aware of their glucose levels—they’re a little bit more aware of trends in their glucose levels.
Let’s say someone was admitted for a heart attack and now they’re waiting for open heart surgery, and we have to receive medication, which is blood thinners such as heparin, which is mixed in dextrose or sugar. While receiving this medication, their glucose starts trending up, and they can alert them or say, “Hey, I feel that my sugar is trending up. Do you mind double-checking or triple-checking the sugar to make sure that we are trending in the right or wrong direction?” That may alert me as an endocrine hospitalist to maybe order a little bit more insulin or just some of another diabetes medication.
RK: That is one of the unique features, isn’t it, of the continuous glucose monitors—those trend arrows and the ability to see what direction the sugars are going, which you may not get from just a few data points throughout the day. Also, the ability of the patient to be involved in their care, to really have an understanding of what’s going on, and perhaps to give a heads-up for instances that may need to be addressed before they become bigger instances. For those who might be listening that are contemplating, why even consider this if it’s a hospital setting that does not yet have a policy? I think that’s a particularly important point: even as a complementary monitoring to what’s standardly done with the finger pricks, it can have value.
We talked about continuing use of continuous glucose monitors upon admission. I wonder if we wanted to talk a little bit about continuing insulin pumps as well upon admission. Are those technologies that are usually continued in the hospital setting? Is it approved to be continued? What do we know about that?
MZ: Yes. If clinically appropriate, and hospitals have proper protocols and staff have appropriate training, then, of course, we have to perform confirmatory blood glucose checks. We are strongly encouraging people to use their insulin pumps in the hospital setting. Sometimes patients may need to stop their insulin pumps, for example, if they’re critically ill or if they’re intubated and have to be admitted to the critical care unit and we are receiving some medications and vasopressors to keep people alive. Obviously, people cannot monitor their own insulin pump, and in those situations, we sometimes discontinue—temporarily—insulin pump use until patients get better. Also, sometimes we know that devices malfunction or if people run out of their supplies, as insulin pumps have to be changed every couple of days. Also, with CGMs, it depends on the type of CGM you have to update it or change it.
If they don’t have any supplies, which is frequently the case because, obviously, nobody comes to the hospital because they know they’re going to come to the hospital and spend a week here, right? Something emergent happens; a person gets a stroke, and they’re being rushed by EMS or 911 to the hospital. To bring additional pump supplies is not the first thing on people’s minds. What I usually do, for example, is I had a patient who had a foot infection the other day, and he came to the hospital just for a quick checkup; he was not feeling well. He had no idea that he had a severe foot infection, so he did not bring any pump supplies, and his insulin pump was running low. My first question to the person was, “Is there anyone in your family who can bring the supplies?” And he said, “You know what? My wife is going to be here in a few hours. Let me call her. She’s going to bring supplies.” In that case, given that his insulin pump still had enough insulin, I allowed him to continue it. But if the answer would be, “You know what? I live alone. There is nobody to bring the insulin pump supplies, and my insulin pump is going to run out in the next few hours,” we would advise him to transition to subcutaneous insulin shots.
JS: Yes, and I agree. Just to chime in with Dr. Z, I think the main key here is for the patient to let the staff know early that they have an insulin pump or for the staff to find out as soon as possible from a nursing skin check on admission. Just making sure, because I think, as evidenced by what Dr. Z says, that interdisciplinary teamwork is so important for the nurse to notice the insulin pump on the patient. If the patient isn’t alert and oriented to tell the nurse that there’s an insulin pump. The nurse finding out on the skin check, letting the doctor know and the doctor consulting from endocrinology to come and get the pump setting. It’s that whole interdisciplinary teamwork that can help these patients to safely continue to use their technologies on admission when it’s appropriate.
MZ: I want to add that in our electronic medical records, which we use here at Johns Hopkins, if doctors document the presence of the insulin pump, let’s say in their history or on the problem list, then there is a little line that appears on the left side of the chart that says “insulin pump in place.” Every single team member, whether it’s a nurse, a consultant doctor, or a patient care technologist, will be alerted that this particular person is using the insulin pump.
RK: As we’re discussing this, I think one of the things to point out is the differentiation from continuing your medications in the hospital. I don’t think there is really ever a situation where we say, “Bring your medicine from home, and we’ll let you take it in the hospital.” Unless it’s really a very specialized drug. But even that is a very rare instance.
What we’re talking about is a little atypical, what we’re saying is that you have a technology you use at home, but you can continue it in the hospital. Part of the reason that this has become more and more of a topic of discussion is because of how good these technologies are in the outpatient setting in helping patients self-manage their diabetes at home.
What would you say is the greatest push to continue these technologies in the hospital? We talked about them briefly with the CGM. What about the insulin pump? Why not just transition to subcutaneous insulin?
JS: I would say because the pumps, especially nowadays with the automated insulin delivery systems, know the patient so well that I think the patient oftentimes needs to receive less insulin overall than they may need if we transition them to our own basal bolus protocols.
MZ: I want to share one more observation. I’ve been volunteering at a camp for children with type 1 diabetes, Camp Possibilities, in Darlington, Maryland, since 2013. Many people who live with type 1 diabetes develop an emotional attachment to their devices, including insulin pumps. It is very important for me as a clinician and a physician to recognize these emotional attachments and preserve this relationship between the person who lives with type 1 diabetes or type 2 diabetes and the use of an insulin pump. Therefore, I strongly encourage people who come to the hospital with their insulin pumps to go above and beyond to secure additional supplies, but I strongly encourage them to continue using the insulin pump in the hospital setting.
RK: That’s an interesting observation that you shared, Misha, and one that makes a lot of sense. You have something that supported your management; it is working well—why rock the boat? I think that’s really what this comes down to, that it’s facilitated the management as an outpatient; it has flexibility to change settings if needed in the inpatient setting too. I think, Jordan, you mentioned in a more granular way perhaps what we can do in some instances depending on the patient with subcutaneous insulin and may allow us to give doses that more closely match the need for the patient as well.
MZ: Yes. At the same time, some people who live with type 1 diabetes or type 2 diabetes or an insulin pump actually want to take a break—and it’s okay. We all know about diabetes fatigue or diabetes burnout. People come to the hospital and say, “You know what? I want to take a break.” I had a patient who was on an insulin pump for quite a while, and she said, “I think I would like to be managed on insulin shots. I’m going to stop the insulin pump. I trust you, take care of me,” and I think it has to be respected as well.
RK: That is exactly true. Thank you for bringing that up. It really is a matter of individual preference, and I think that’s what we’re talking about here today: allowing the person with diabetes to have the option of continuing the technology if they’d like or taking a break if they’d like—really having that option that best meets the needs of the situation at hand.
We talked briefly about guidelines for diabetes technology use in the hospital. I wonder if there was any other information that you both wanted to share regarding current guidelines for the use of both CGMs and insulin pumps in the hospital, both for type 1 and type 2 diabetes.
MZ: We know that the latest research shows the use of continuous glucose monitors in the hospital can improve detection of nighttime hypoglycemia, which is low blood sugar, and can also help reduce recurrent low blood sugars.
The American Diabetes Association 2025 Standard of Care guidelines say that CGMs, or continuous glucose monitors, should be continued in the hospital if clinically appropriate and if blood glucose checks are done for confirmation.
The same thing goes for the insulin pump and automated insulin delivery system, which can be continued as long as the patient can manage them. There are situations where patients cannot manage them—they’re not well enough, but there is a family member who is by the bedside who can help them out with some of the management.
But the key to success is not just the person who is feeling comfortable with his or her insulin pump or continuous glucose monitor; it is to have trained personnel, trained nursing staff, and clear protocols in place that can safely integrate that use of diabetes technology into patient care.
JS: Yes, that’s exactly right, Misha. One of my goals is to really get into our nursing orientations, which we’ve already done, and the nurses have a whole hour with me to talk about our insulin protocols. But we’ve also recently added a section on CGMs, just so that the nurses can get comfortable with knowing what these devices look like, what brands there are, and just getting comfortable with how to manage them—not for the patient, but if the patient has it, just knowing what to do with that CGM.
We want to have these structured policies for continuous glucose monitors and insulin pumps that will help us see better glucose control, do fewer finger sticks, and, of course, have that patient-centered care and satisfaction that we were talking about so that they can keep their devices on.
I think our goal is to have the nurses so comfortable with them that they know, “Oh yeah, this is the policy, this is what we do when we see that type of device.” To help the patient as best they can to keep those devices on them, if that’s what they desire.
MZ: Last year, in 2024, our hospital got a grant from one of the companies where we received 70 sensors, and we trained a group of leader nurses from most of the unit and pharmacists and some of the dieticians as well on how to use the CGM. But what’s most important, we did not just train them; we created an opportunity where nurses and pharmacists were able to wear a continuous glucose monitor for a week, 10 days, or 14 days. However long they wanted to wear one, so they can not just understand what it’s like to wear a continuous glucose monitor. We can also experience it as well, and I strongly encourage other hospitals around the country to participate in those trainings and hands-on experiences as well.
JS: I can say as a person not living with diabetes, I feel like I learned the most about continuous glucose monitors when I wore them. That’s when you realize how many alerts go off overnight, and you get a sense of how a person living with diabetes might feel—being woken up during the night, having an alarm go off during your meeting because your blood sugar’s low, and all those things that you might not think about just taking someone through a tutorial of how to use them. I think having the nurses wear them and live with them, like Misha said, for 10 days to 2 weeks, you can learn a lot about what someone living with diabetes would go through.
RK: If the medical condition allows that this is something that could really benefit the patient, that with the nursing staff. It’s interesting to hear about the pilot program you had where the nursing and medical staff were able to wear it themselves so that they too could understand more about this technology.
I’m just curious; part of the hesitation perhaps about continuing these technologies in the hospital may be due to the patient’s reason for admission—that it may be unpredictable and that it may lead to challenges in management if the patient’s condition is not stable. I’m just curious, what situations, if you could give us examples, might lend themselves well to continuing these technologies in the hospital or, conversely, such as the ICU setting, I would imagine it might be more challenging to continue an insulin pump if someone’s intubated. I wonder if you might be able to give a brief insight into situations when these could be considered or not considered.
MZ: Most commonly patients ask me, “Can I wear an insulin pump during the surgery?” My answer is I quickly often get a phone call from a pre-op (pre-op stands for preoperative evaluation) department, which consists of excellent nurses who evaluate the patients prior to their scheduled surgeries. My answer for the nursing staff is, “It depends.” If a person with diabetes who is wearing an insulin pump is under anesthesia and unable to self-manage, and the procedure lasts a long time, let’s say it’s open heart surgery, they should probably discontinue the insulin pump. Remember that the surgical stress and some of the medications that are administered during the big surgery can impact blood sugars in quite unpredictable ways.
Sometimes patients require vasopressors or medication, which supports their blood pressures, and in those cases intravenous insulin, which is the insulin administered directly into their vein, is probably the safest method to provide good glucose control during those procedures. And Jordan, do you want to talk about some of the minor procedures?
JS: For a lot of the minor procedures, where patients might be awake or asleep for a short period of time, some hospitals may allow for their insulin pumps to continue to be on them and working. Our hospital is one of those. But we do recommend that patients talk to their surgical team in advance to discuss the options for whatever equipment they might have. I have meetings with our pre-surgical staff all the time just to talk about their pre-op management of the blood sugars, and so it’s really best to communicate with them so they can tailor the specific recommendations for the patient based off of the surgery they’re going to get.
RK: It sounds like it is a discussion between the patient and the team to understand the needs of the surgery, how long the surgery will be, and whether it’ll be more beneficial or not as beneficial to continue it during that aspect.
MZ: Sometimes surgeons may not have an answer to this because it’s really the anesthesiologists who are making the decision whether the insulin pump should be continuing during a particular surgery. Kindly ask the surgeon to connect with the anesthesiologist and quickly discuss it. Of course, if you’re admitted to one of the Johns Hopkins Hospitals, there is also, usually, an endocrinologist who is involved in the care. I ask our pre-op team, “Hey, send me a quick message.” And if there is a person, and they have a question about whether to continue or not, I’ll come and help out.
RK: That’s an important point. Thank you for bringing it up. It is definitely important to have coordinated care among everyone on the team: the surgeon, the anesthesiologist, the endocrinologist, the primary team, the nursing staff, and, of course, at the center, the patient. We’ve talked a lot about people who’ve been on these technologies before they came into the hospital and continuing them. But what about patients who might have heard of these technologies? Perhaps they hadn’t really had a chance to talk about it with their provider, or maybe they just weren’t familiar with them. This seems to be an opportunity in the hospital setting to provide education and also to discuss the opportunity or possibility of starting technologies, particularly continuous glucose monitors, I think is what we’re talking about here. Insulin pumps might need a more intricate discussion to start as an outpatient, but for those who might want to consider the continuous glucose monitor in the hospital, can this occur? Would it be something that, in your experience, you recommend, and how can we have success for those that do start it in the hospital once they leave?
MZ: I want to say absolutely. Whenever possible and whenever I suspect that a person’s health insurance is going to cover a continuous glucose monitor, I try to allow people who live with diabetes to at least experience a continuous glucose monitor at the time of discharge. What we do is we participate in the CGM on discharge program where, when we know the patient is ready to be discharged in the next 24 to 48 hours and they fit a particular criteria, what usually happens is I ask the patient, “Hey, would you like to try a continuous glucose monitor? I think it really can help you to control your sugars in outpatient.” Then I call Jordan.
JS: Yes, that’s where I come in, or any diabetes educator. It’s a unique opportunity, I think, in that 24 to 48 hours before they go home, for what our hospital does. You can bring in demonstration sensors for the patient to feel and touch and say, “This is what it’ll look like when it’s on your arm.” Then download the app—“Let’s set it up. Let’s create an account for you.” Then once it’s downloaded, we can walk them through and say, “This is where your logbook is going to be.” You can really do a step-by-step tutorial with them, not only putting their first sensor on for them but then setting up the entire app, which for a lot of patients, once they get home from the hospital, they might not want to do on their own, which is totally understandable—they just got home from a long hospital stay, and they’re exhausted. The last thing they probably want to think about is what to do with their new CGM.
Rather than just giving them the box and saying, “Okay, here it is, best of luck. Pick it up at your pharmacy.” Really going through that step-by-step process with them and showing them how it works, I think, is beneficial to give the patient that autonomy. I see patients all the time with family members at the bedside who are there to help them, and we can help them set up. With the apps that have been created, the patient has their alerts on, but then the family members also get notified when the patient’s blood sugar is low or high. It creates a safer environment for patients, and I think it really just tees them up for success when they leave.
MZ: I’ll share an anecdote. We had a patient last week who came to the hospital because of nausea and vomiting, and he was found to have a hyperglycemic crisis. We hydrated him. He was feeling better, but because his diabetes was so uncontrolled, we were essentially forced to suggest starting insulin, even though it’s not our first-line therapy, but we started insulin. The person was quite anxious; he had never checked his glucose before. I suspected, and I checked his insurance; we ran his insurance, and it sounded like it would be covering the continuous glucose monitors. I called Jordan, and she came and set it up. The patient was very happy, and then a few days later, we were able to schedule him for the diabetes health management training program with an outpatient diabetes educator. She, the outpatient diabetes educator, was already able to download the data from the previous few days and insert it into the chart and shared it with other practitioners in our practice, which was absolutely terrific.
RK: That’s a wonderful story and highlights the importance of having data in order to make management decisions. As we mentioned before, even the alerts for someone who’s at risk for some of these really severe complications, such as hyperosmolar hyperglycemic syndrome or even DKA, to be alerted to high blood glucose numbers before they enter the hospital could have tremendous value. I think it’s important to emphasize that we really are talking about giving patients options here. When we talk about the use of technology, some people may prefer not to use the technology.
But we know for those that do choose to use them, particularly those with type 1 diabetes, there has been a lot of evidence to support their potential benefits even in people with type 2 diabetes on insulin and now emerging evidence for people even not on insulin. I think this is an ongoing conversation, but an individualized conversation, as we talked about, might depend on the preferences of the patient and their particular situation.
Moving a little bit now to a separate but related topic, we talked about diabetes technology and really from the perspective of the person living with diabetes or admitted to the hospital. But what about from a population level or a health system level? How can the use of diabetes technology impact quality of care in the hospital setting?
MZ: I think it’s a wonderful question, and I’m looking forward to learning more as more research comes on this particular topic. The way I envision that is that CMS (which is the Centers for Medicare and Medicaid Services) announced a few years ago that they’re going to track severe hyperglycemia, which is high blood sugar (more than 300), and severe insulin-induced hypoglycemia (glucose less than 40) and just keep an eye on that. The hospitals that are not reporting by 2026 are going to be penalized. I suspect that in the next few years hospitals that are really the outliers, hospitals that, let’s say, have too much of the severe hyperglycemia, may even be penalized by Medicare for not performing well, and that’s where the technology is going to come into place.
Just think about it: if you can get FDA approval for the use of CGMs in the hospital, we can maybe reduce the need for the finger sticks. We can get a more real-time glucose trend. Maybe we’ll be able to detect more “silent low blood sugars.” Quite often people go to sleep at night with a glucose which is 150, which is normal in a hospital setting. Then we may develop low blood sugar, but unless you check it, nobody knows about it. Some people may have a lot of glucose variability when patients’ sugars go up and down, and of course you will never know about this unless you have the trend; you have the data.
Finally, a lot of people think about the quality of care from the perspective of “sugar number this, sugar number that, numbers…” I don’t believe that the quality of care lies in an actual number. It’s all about improving the patient’s comfort and enhancing the patient’s experience while they’re in the hospital.
RK: That’s so important, and I think you’re absolutely right. It’s not just the numbers, the A1C or the sugar number. It’s really the quality of the experience, the patient care experience. It sounds like having more data; detecting these otherwise silent or missed episodes of hypoglycemia, that could be asymptomatic, especially in people with longstanding diabetes; this gives us more information in terms of how the interventions we’re using in the hospital are impacting the medical care of the person with diabetes. It’s an emerging area. I’m sure we’ll learn more in the time to come, but one where I think we will see technology marry quite closely with quality of care goals in the hospital.
We talked a little bit about the importance of education, especially for healthcare providers and nursing staff in the hospital, to ensure the safe use of diabetes technologies and also education for patients. I wonder if we could just briefly talk about what we mean when we say “education.” Are there certain aspects that Jordan, you especially, I’m imagining, spend your time educating individuals about?
JS: Absolutely. Within the American Diabetes Association and the Association of Diabetes Care and Education Specialists, there’s what we call the seven diabetes self-care behaviors, which I think is really what our education focuses on in the hospital. Whether it’s monitoring your blood sugar, healthy eating, or medication adjustments, these are all things that someone living with diabetes often experiences changes with when they’re in the hospital, especially medications. If they’re admitted and their A1C has gone up since the last time they were seen by a doctor, and now we’re changing all their medications and the nurses are busy and the doctors are busy. The educator is there to sit down with the patient and say, “Hey, this is what’s going to change once you get home. This is how you’re going to give yourself the medication, how many times a week,” all those specific details that can be a lot to manage. As Misha mentioned, diabetes distress is a real thing—I think a lot of patients that we see in the hospital are extremely overwhelmed, whether they’re newly diagnosed or they’ve had diabetes for 20 years.
To get back to the question, I think diabetes education really is focused on so many different areas, but the educator is really there to help break it down and figure out what the patient needs to focus on. Like we talked about before, it’s very individualized. A patient might be really comfortable with their nutrition plan and checking their blood sugar with finger sticks, but maybe medication compliance is difficult for them. The educator can focus on those individual facets of diabetes education with them.
RK: There’s so much that could be potentially covered; it could take a long time. But I think those priority areas, the seven topics that we emphasize in diabetes self-management education and support programs, or DSMES, are particularly valuable.
It’s an ongoing process, and it’s just the start in the hospital, but it does lay a nice framework for integrating the use of these technologies and making sure everyone feels comfortable and familiar with them.
Just a parting word: we cannot talk about technology for diabetes without talking about the technologies that we use for our patients in general, which are electronic medical records. I know that in the outpatient setting, in the clinic setting, we can often download data from continuous glucose monitors or insulin pumps, for instance, into our electronic medical records. What about in the hospital setting? How straightforward or easy is it in that setting?
MZ: That’s an amazing question because we are not there yet, but we are working on this. The Johns Hopkins Health System is in the final stages of integrating our electronic medical records with the data that accumulated from the continuous glucose monitor. A provider or a physician would be able to send a quick electronic message through the MyChart app to the person who is wearing a continuous glucose monitor and sign a consent form, and the data will flow into our electronic medical records, but we are not there yet. It’s coming, but we are not there yet.
RK: How neat would that be, you imagine seeing these screens in the hospital with the vital signs, the cardiac monitor, the oxygen monitor, to see the glucose patterns superimposed or overlaid on that? I think we’re just talking about more data, more information, and more ways for us to better understand how the patient’s medical condition is evolving and responding to the treatments that we give in the hospital setting. More to come, but very exciting.
MZ: My dream would be to have CGM telemetry in our hospital where nurses would just have to have a glance, and we’ll have all the patients connected to continuous glucose monitors and to see where the trends are.
RK: Wow, wouldn’t that be so neat? I can’t wait for the future. That sounds so exciting. I just wonder, Misha and Jordan, we’ve covered so much ground today, and it has been so great to hear about all the different ways that diabetes technology, particularly continuous glucose monitors and insulin pumps, for those who are already wearing them at home, can be safely integrated into the hospital setting. But with the caveat that it depends on the individual, it depends on the condition, and it depends on the hospital setting and familiarity of the nursing staff. Then also the opportunity to start continuous glucose monitors for the first time for those who may be considered good candidates or are interested in the hospital setting.
For our listeners who may be interested in learning more about how they can continue to use these technologies in the hospital or whether their hospitals even allow this, what would you recommend?
MZ: At the time of that admission, when we’re coming to the emergency room, please check in to see if they have an endocrinologist on staff who would be able to help out and be consulted. We are always happy to talk to people and help them with diabetes technology.
RK: Thank you again Dr. Misha Zilbermint, and Jordan Spivak. It’s been such a pleasure to have you both in our podcast, and we truly appreciate all your expertise and input today.
MZ: Thank you
JS: Thank you.
RK: I am Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit hopkinsdiabetesinfo.org.
We love to hear from our listeners. The email address is hopkinsdiabetesinfo@jhmi.edu.
Thanks for listening. Be well and see you next time.
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- Home - | - Episode 47: Diabetes and Substance UseIn Episode 47, Dr. Kalyani welcomes Anika Alvanzo, MD, MS, FACP, DFASAM. Dr. Alvanzo graduated from George Washington University School of Medicine and Health Sciences, has a master’s in biostatistics from Virginia Commonwealth University, and is board certified in Internal Medicine and Addiction Medicine. She is a Principal at Health Management Associates, where her consulting has focused on supporting state and local jurisdictions in community needs assessment and strategic planning for behavioral health service delivery; provision of training, technical assistance, and coaching to behavioral health providers; training on and implementation of the ASAM Criteria; and advancing cultural humility and health equity in addiction treatment. As a national leader in addiction medicine, Dr. Alvanzo has served as a subject matter expert on national panels, including the National Institutes of Health, Substance Abuse and Mental Health Services Administration, National Quality Forum, and PEW Research Center on topics such as opioids and chronic pain, quality metric development and medication for opioid use disorder (MOUD) integration. Her publications span topics including gender, race, and ethnicity differences in the trajectory of and service utilization for substance use disorders and the association between psychological trauma, post-traumatic stress, and substance use, particularly in women. Dr. Alvanzo is a Distinguished Fellow of ASAM, currently chairs the ASAM Annual Conference Program Planning Committee and is Secretary of the ASAM Board of Directors.
DOWNLOAD TRANSCRIPTTranscript: Podcast 47 - Diabetes and Substance UseDr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.
Today we are thrilled to welcome Dr. Anika Alvanzo, who will speak with us about diabetes and substance use. Dr. Alvanzo graduated from George Washington University School of Medicine and Health Sciences, has a master’s in biostatistics from Virginia Commonwealth University, and is board certified in internal medicine and addiction medicine. She is a former faculty member at Johns Hopkins University and currently a principal at Health Management Associates, where her consulting is focused on supporting state and local jurisdictions in community needs assessment and strategic planning for behavioral health service delivery, provision of training, technical assistance, and coaching to behavioral health providers, training on an implementation of the ASAM criteria and advancing cultural humility and health equity in addiction treatment.
Dr. Alvonzo’s publications span topics including gender, race, and ethnic differences in the trajectory of and service utilization for substance use disorders and the association between psychological trauma, post-traumatic stress, and substance use, particularly in women.
Welcome, Dr. Alvonzo.
Dr. Anika Alvanzo, MD, MS: Thank you, Dr. Kalyani, it’s great to be here.
RK: We are so excited to hear from you today about the intersection between substance use and diabetes. This may not be something that people immediately think about as being connected, so I wonder if you could first start by telling us: what is a substance use disorder, and is that even the right term that we should be using?
AA: Yes, substance use disorder is the right term. Substance use disorder is actually the diagnostic term that we use to characterize the disease of addiction. The American Society of Addiction Medicine, or ASAM, defines addiction as “a treatable, chronic medical disease involving the complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences.” When we talk about substance use disorders, substance use disorder is the compulsive use of substances despite adverse consequences, and those consequences ultimately lead to either physical and/or psychosocial functional impairment.
When we’re discussing substance use disorders, there are 11 criteria that we use to define substance use disorder or make the diagnosis. I typically like to group them into three categories: physiology; criteria that are indicative of loss of control over one’s use of substances; and then criteria that are indicative of the associated consequences of use.
Examples of physiology would be tolerance, meaning that somebody needs to use more and more of a substance to get the same effect. Another [example of] physiology is withdrawal. If somebody stops using a substance abruptly or dramatically reduces the amount of substance that they’re using, they may have symptoms or a withdrawal syndrome. Those are the two criteria that fall under the category of physiology.
Then things that may be indicative of loss of control—so inability to cut down or control use, using more than originally intended, giving up important activities in order to use a substance, craving, spending a great deal of time either obtaining a substance, using the substance, or recovering from the effects of the substance.
Then, criteria that reflect associated consequences of use. That would be things like the development of physical or psychiatric problems associated with use and continued use despite those problems or exacerbation of those problems; role failure—not meeting obligations at home, at school, or in the family; interpersonal problems, either again with loved ones or with others; and use in hazardous situations.
So those are examples of the 11 criteria that we use. And then once we make the diagnosis, we stratify it based on severity—mild, moderate, or severe—with mild being two to three, moderate being four to five, and anything six or more being associated with a severe substance use disorder.
The only other thing I’d say is that substance use disorders are chronic diseases. Just like other chronic diseases, they are characterized by periods of remission and periods of recurrence. I think it is important to know that prevention efforts and treatment approaches for substance use disorders are generally as effective as those for other chronic diseases. While many times people with substance use disorders are stigmatized, we know that substance use disorders, like other chronic diseases, with effective treatment respond as well as other chronic diseases like diabetes, for example.
RK: Thanks so much for breaking that down for us. That was quite a bit of information, and it’s good to know about how this might be different than substance use in general. I think many of us could understand what substance use is. Could we clarify when we talk about substance abuse, what substances are we talking about?
AA: It varies; it can include what are considered legalized substances: that’s alcohol, tobacco, or nicotine (which is the active ingredient in tobacco). In our state and many others, cannabis is now a legal substance, and then there are opioids, which can be obtained either legally via prescription or illegally on the street, and stimulants like cocaine, methamphetamine, and hallucinogens. Any substance that has the potential to be addictive. Caffeine is another substance that we often don’t think about but that can be associated with disordered use.
RK: Thanks for going through all of those because, like you mentioned, some are more common, like caffeine. I think many of us can relate to that, whether it’s coffee, tea, sodas, or other products versus others that might be legal in some states versus others—you mentioned cannabis being legal here in the state of Maryland, but that might differ across the country. Then those [substances] that tend to be restricted or illegal across the United States.
When we talk about substance use, it sounds like there’s a spectrum of what we’re talking about. When we talk about substance use versus substance use disorder, you had outlined for us those criteria of what makes it a disorder. It sounds like things that impact daily life, things where you may become addicted or really need it more for the high or the effects that it has, or having used it so much that it interferes with your usual functional activities. Is that right?
AA: I think it’s important to know that there are a range of ways that people use substances. Some people never use substances, and then some people may engage in what we call experimental use or social use, and then some people are on the continuum where they are using substances chronically, and their use of substances has subsequently resulted in consequences that then lead to functional impairment.
When we talk about substance use disorder, we’re talking about the compulsive use of substances in the setting of continued consequences. You mentioned that there are different substances. I think again, there’s a lot of stigma related to the disease of substance use disorder, or people with a substance use disorder. But I think we also recognize that, whether the substance is considered a legal substance or illegal, the process of what’s happening in the course of a substance use disorder is the same. Somebody who has a nicotine use disorder and somebody who has an opiate use disorder—while the receptor systems in the brain may be different, the neurobiological changes that are occurring in the brain with chronic substance use are very similar. Hopefully, that will help reduce some of the stigma associated with substance use for patients and people who are listening.
RK: I was struck by what you said: it is using these substances, whatever ones they are, despite the consequences, despite knowing how they’re affecting someone’s daily life or affecting others around them. You mentioned the stigma, the fact that this is a disease that can be treated, and then really addressing the stigma that might otherwise be there, that this is due to neurobiology—this addictive potential—and it can be treated. When we talk now about substance use in diabetes, are people with diabetes at higher risk of using substances? Or, what is the interaction of these two conditions?
AA: I am not aware of data that suggests that people with diabetes are significantly more at risk of using substances. What we do know is that when somebody has a substance use disorder, particularly an active substance use disorder, it is not uncommon for them to have poor outcomes for other co-occurring diseases that they may have, including diabetes. Often in the midst of an active substance use disorder, people are not attending to their health, to their medical appointments, to the monitoring of their blood glucose, or to taking their medications to treat their diabetes.
I do want to say, though, that there are some substances that may be associated with a higher risk of developing diabetes. So not looking at people with diabetes who may be more likely to use substances, but looking at people with a substance use disorder who, because of their substance use, may be at greater risk for developing diabetes.
There is data that suggests that chronic use of nicotine may be associated with higher rates of diabetes. Specifically, nicotine may have some role in increasing insulin resistance. Then there’s data with respect to alcohol. In terms of the mechanism for alcohol, we know that chronic heavy drinking can result in pancreatitis. The pancreas is the organ that produces insulin to monitor or regulate our blood sugar. Particularly in the setting of chronic pancreatitis, you can get damage to the beta cells in the pancreas, which are the insulin-producing cells. With long-term damage, what ultimately happens is people get enough damage to those beta cells that they can’t produce insulin. Then they develop diabetes associated with the pancreatitis that they developed as a result of their alcohol use disorder.
RK: You mentioned nicotine or smoking. We know that smoking is a risk factor for cardiovascular disease, or heart disease, and that people with diabetes, especially, are at higher risk for developing cardiovascular disease. Clearly, having both is not a good combination. Then you also mentioned that nicotine can contribute to insulin resistance in some situations, which is very interesting, that there could be an underlying mechanism by which it could contribute to the development of diabetes.
AA: There is some data to suggest that this year ASAM released the seventh edition of his text with the principles of addiction medicine (2024), and in there, there is a chapter that looks at the endocrinologic effects of substance use. They talked about how, for people with chronic nicotine use, there does appear to be an increased risk of the development of diabetes. There appears to be a sex-related effect, such that men who are current smokers have greater risk than women. As you said, we know that nicotine use, particularly cigarette smoking in and of itself, can lead to a number of consequences that look similar to long-term diabetes and cardiovascular consequences. It is difficult to say in this instance if this is a result of nicotine itself or, more likely, the byproducts of cigarette smoking. But yes, if you’ve got somebody who has both diabetes and is smoking cigarettes, then you are looking at an exacerbation or increase in their risk for developing these cardiovascular complications.
RK: Yet another reason to cut down on nicotine use, isn’t that right? Now you mentioned alcohol and the relationship of pancreatitis, which, as described, you could get alcohol pancreatitis, and that could be related to diabetes development too. I have always been struck by what seems to be at times conflicting data about alcohol use and diabetes risk. I seem to recall that there has been literature suggesting that maybe one or two drinks a day can be protective. Can you talk about that?
AA: There is some literature that suggests that lower amounts of alcohol may be protective or may result in a decreased risk. But when we’re talking about alcohol-associated pancreatitis, that occurs in people with chronic, heavy drinking. So drinking that exceeds the recommended limits chronically (for an extended period of time). So yes, at times there does appear to be almost this U-shaped or dichotomous risk for alcohol based upon whether it’s low-level drinking within the guidelines or when we have people who engage in chronic, heavy drinking.
RK: It does seem like with that mild to moderate use, there has been mixed literature. But what we’re talking about here today is the heavier use, the substance use disorder that could be associated with alcohol, and the adverse outcomes that could be related to that in addition to the development of diabetes.
Some of the other substances that I know have been described in relationship to diabetic ketoacidosis and that I have seen during my medical training are the use of cocaine, and one of the things that I have wondered is whether the use of these substances, such as cocaine, and the relationship to the development of ketoacidosis, especially with type one diabetes, is more related to the effects that the substance has on the person, so they can’t manage their diabetes as well, or whether there’s an effect of the substance itself that puts people at greater risk of developing these hyperglycemic complications. I wonder if you might have any comments about that.
AA: I am less familiar with data on cocaine in terms of its impact on the metabolism of glucose. I would venture to guess that in those instances, it is more likely to be associated with someone’s use being so disruptive or, again, when we talk about that functional impairment, that it’s impairing their ability to successfully manage their diabetes.
RK: So it sounds like it is both, depending on the substance—either a direct potential mechanistic effect or effect on the insulin signaling in the body, like in the case of nicotine that could put someone at higher risk for diabetes or higher blood sugars in general, or probably more generally with these substance use disorders, the disruption of the daily routine and the management. We know that self-management at home is so important for diabetes, and so having a substance use disorder on top of that just makes it much more challenging. I wonder if, in an individual who has both these conditions—who has diabetes and a substance use disorder—it is like a chicken and the egg question: which came first or which to address first. I am sure it is a multipronged approach, but I was just wondering if you could outline for us some general strategies or approaches that you might recommend for a person with diabetes who is challenged by these substance use disorders and how to address them in practice.
AA: We often have this conversation, particularly because we know patients with substance use disorders can have a number of co-occurring conditions, whether it’s a co-occurring biomedical condition or psychiatric condition. Traditionally, we used to have this co-occurring psychiatric condition. Do we treat the psychiatric condition first, or do we treat the substance use disorder first? Inevitably, what research has shown us is that an integrated approach where you are addressing both things concurrently is the most effective treatment. We know that with somebody who has diabetes that is poorly controlled, we need to help them in terms of the management of their blood sugar. But if they’ve got an active substance use disorder, their ability to successfully manage and gain control of their blood sugar is limited.
Ideally, you want to address both at the same time. Ideally, in an integrated setting, we know that is not always possible, but if somebody is being treated for their diabetes in a primary care setting, if the primary care setting is able to integrate behavioral health treatment focused on managing one’s addiction or at least screening to identify the presence of a substance use disorder and then appropriately linking to treatment, assuming patients are willing to go, that is the most effective approach to try to address both at the same time.
RK: It seems like it should be an integrated approach to addressing both conditions. For our audience: an individual who may have diabetes who is wondering, “I use substances; is it too much, or is it okay?” How would someone know whether they may have a substance use disorder? What symptoms might they see in themselves? Or how could they get a better insight into whether their own behavior is disruptive?
AA: I think one of the things is, again, looking at how they’re using substances; what are the substances doing for them, and then what is the impact of their use of those substances? If somebody is having a drink every now and then, or smoking cannabis every now and then, but not having any consequences associated with that use or any functional impairment associated with that use. Then it is less likely that they have a substance use disorder. It is when somebody is starting to have consequences associated with that use, and they’re continuing to use or find that they are not able to stop or cut down on their use despite those continued consequences. In terms of how to identify that; one is having a conversation with their medical provider, and there are a number of different screening tools that you could find online as well that they could search. The ASSIST is an acronym for the Alcohol, Smoking and Substance Involvement Screening Test. The ASSIST covers all substances. There’s the AUDIT or AUDIT C, which is the Alcohol Use Disorders Identification Test. There’s a full audit and then there’s also the audit C, which is the first three items, specific to alcohol. But again, those are some publicly available tools that can be used either in a clinical setting or if somebody wanted to search those tools online. But I would say if somebody had concerns, my encouragement to them would be to have a conversation with their medical provider.
RK: Those are great tools to know about. I agree; with any level of concern bring it up: bring it up to your healthcare provider or bring it up to a family member. Speaking of which, what if you are a caregiver of someone with diabetes and you’re concerned they may have a substance use disorder? How do you think a caregiver should gently approach it? I can imagine you mentioned the stigma attached to it. I can imagine that even the person who has the disorder might also have strong feelings about it.
AA: Yes. What I think is important for caregivers and for others to know is that chronic use of substances causes changes in the brain and changes in the brain in a number of areas, including the reward center. So that it hijacks the reward center of the brain. Initially, when people are using substances, they get a spike in the release of dopamine, which is the primary reward neurotransmitter. But over time with chronic use, that reward center essentially down-regulates itself so that it becomes even more difficult for somebody to have a release of dopamine with an activity that would normally have provided a reward—spending good time with family and friends, a great workout, or something that would normally provide a natural reward; that reward system gets downregulated. It becomes more and more difficult for people to experience pleasurable events. There were many times in my treatment career where I have had patients say, “At this point, I’m not using to get high. I’m using to feel normal.” So you have that and changes in the stress response system, and then you’ve got changes in the stress response system—that fight or freeze system. So you get changes in that system such that particularly when people are going through withdrawal, they have an increased response, a stress response that then motivates the behavior to continue using, particularly in the setting of substance withdrawal.
Then there are chronic changes that occur in the air of the brain that deal with what we call executive function. So that’s things like decision-making, impulsivity, and judgment. Sometimes initially, it can be difficult for an individual to recognize in themselves that they are having a problem with substances. So again, I think as a caregiver, one thing I would encourage is to not give up on your loved one or the person for whom you are caring. Try to involve as many people as possible; so again, if the caregiver has a concern, bring that concern to the attention of the medical provider.
I think it may be helpful for the caregiver to identify resources in the community that may help support them in their caregiving journey. Whether that is Alina or there are support groups that are specific for people who are loved ones or who are caring for those who have a substance use disorder, getting support for themselves.
But I would just encourage them to recognize that it is their loved one; the behaviors that they may be seeing in a loved one who has diabetes but may also have a substance use disorder are not a reflection of a moral failing or a personal choice. There are chronic changes that are happening in the brain. I think helping family members and even clinicians who don’t work in the addiction space be aware of that, hopefully, will allow people to have more patience and grace as they are working with individuals who may have a substance use disorder.
I can tell you; I did some caregiving for both of my parents before they passed away—caregiving is hard. As much support as you can get, just caregiving alone is hard, let alone adding caregiving for somebody who has a substance use disorder. Get as much support and resources as possible. Then again, bring it to the attention of the medical providers so that they can provide additional support.
RK: It’s great to hear about the importance of a good support system, as you mentioned, even support for the caregiver, which can be challenging. I appreciate you sharing your own experiences as well. When we talk about treatment, then, at the point where someone is ready for treatment, as you mentioned, it might just not be to get high anymore but really could be that they have a reset in their brain, that this is their new normal. So it would be understandable that it takes time to reset the brain again. Then also the withdrawal effects that I know some of these substances can have when you stop taking them and your body’s used to them. I wonder if you could talk just a little bit about the withdrawal strategies in general and treatments that are available for people having withdrawal symptoms. Are these the kinds of things that require being in a preserved program, or can people get treated for these substance uses at home?
AA: That’s a great question. I think it depends, so it is going to be individualized. When we think about withdrawal syndromes, all substances actually have a withdrawal syndrome. Some of them may be a little shorter or maybe less severe than others. The withdrawal syndromes that we are most familiar with, particularly when somebody may need to come in contact with medical treatment for them, include alcohol withdrawal, benzodiazepine withdrawal, and opiate withdrawal.
Starting with alcohol and benzodiazepine withdrawal, those depending upon the severity of the withdrawal can require inpatient medical treatment for management of that withdrawal. Again, this is why when we are talking about caregivers or family members who may be working, it’s so important to involve the medical professionals. Make sure the medical team is aware because some of these withdrawal syndromes may require inpatient management depending upon the severity of the symptoms. For opiate withdrawal, there are some instances where it may require inpatient management, but it often can be managed in an ambulatory setting with the initiation of medication.
For those three withdrawal syndromes in particular—alcohol, benzodiazepine, and opioid use—there are medications that are available to manage that withdraw. For alcohol and opiate withdrawal, some of those medications can also be used for ongoing treatment. I think it’s important to know that there are medication treatments available for some substance use disorders, not all, but for some of the substance use disorders, we have medication treatments available.
Then for others, for all substance use disorders, there are behavioral or psychosocial treatments that are available. Again, figuring out what’s available in your community, and again, hopefully your medical professionals can assist you in accessing what is available in the community.
RK: I think it’s so important to emphasize what you just said—knowing what the resources are in your community and then knowing that there are medications out there to help with these three withdrawals, especially mentioning the benzodiazepines, alcohol, and opiates. And that a host of behavioral and psycho-social interventions are available for any of these substance uses. It is important to emphasize that there are many different treatment options, and it sounds like the first step is acknowledging and diagnosing or identifying the substance use disorder.
AA: Yes, absolutely. You have to be able to identify it in order to treat it and recognize that again, there are potentially multiple paths to treatment and, for each individual, that path may look different. There is no right or wrong path to recovery. While some people may use medication in the treatment of their substance use disorders, others may not; whether you use medication, behavioral treatment, or both—it is an individualized decision.
RK: When we talk now about people with diabetes specifically, and we think about the communities that are affected by diabetes and the communities that are affected by substance use disorders—are there overlaps, or can this really impact anyone of any background?
AA: Yes, I think it’s important to know that substance use disorders can affect anyone in terms of any demographic, any race, or ethnicity; there’s no respect of socioeconomic status, geographic location, sex, gender, or sexual orientation.
Anybody can be affected by substance use disorder. However, we do know that there are disparities with respect to race and ethnicity in terms of who is more likely to die from their substance use disorder, particularly when we’re talking about the current overdose epidemic that we are in.
There is clear data that Black people, particularly older Black men and Indigenous people, often younger Indigenous women, are at increased risk for dying from their substance use disorder or dying in the setting of overdose. There is also clear data on disparities with respect to access to treatment, both racial and ethnic disparities.
There are disparities by disability. So people with physical and medical disabilities who have a substance use disorder, particularly an opiate use disorder for which we know there are effective medications, are less likely to be prescribed medication than people without a medical or physical disability.
There are differences in risk based upon sexual orientation or gender. So there are disparities and inequities in substance use disorder. We also know that some of the same populations that are disproportionately affected by diabetes may also be disproportionately affected—not disproportionately affected in terms of the rate of substance use; there is no data to suggest (with the exception of some communities) that the rates of substance use are higher. We do find that the rates of consequences associated with substance use tend to be higher for racial and ethnic minorities and some of the other groups.
RK: Thank you for pointing out those disparities in consequences, resources, and outcomes that can occur among different populations, especially ethnic minority populations or other minority populations as well. We know that diabetes in general has health disparities and inequities that may also contribute to part of that outcome that you’re describing with substance use disorders. Addressing the availability of resources and making sure that people have equitable access to care is very important.
I thought that we could touch base on the opioid epidemic; you mentioned it briefly. We have not talked about it in the context of diabetes. There has been some literature to suggest that because people with diabetes might be more likely to have chronic pain due to peripheral neuropathy, vascular disease, or other complications related to diabetes, they might be more likely to be prescribed opiates as well.
I wonder if you are familiar with or have some insights into the use of opiates and those with chronic diseases in general and what you might say in terms of the use of these pain medications versus non-opiate therapies, for instance, in these populations.
AA: One thing I will say is at this point I no longer refer to it as an opioid epidemic; that is where it started. At this point, I call it an overdose epidemic because we are seeing an increase in deaths from multiple substances, in addition to opiates, often in combination with opioids. Yes, the current epidemic did start with—admittedly, it started with the medical and pharmaceutical industries and our prescribing practices with respect to pain and utilization of opioids for pain.
What we have seen is that over the years those prescribing practices have changed. Sometimes you wonder if the pendulum swings too far because there are some people who do have chronic pain, whose chronic pain may best be managed with opiates, who saw a sometimes-inappropriate reduction in their opioid use from it or their opiate prescribing to manage their pain.
I want to be cautious about this; certainly we need to be more judicious in terms of our prescribing of opioids—while making sure that we do not go too far in the other direction, where people who are in chronic pain who are benefiting from their opioids and not having evidence of an active substance use disorder to their opiates are being removed from opioids.
So that being said, yes, it did start with the prescribing of opioids. Many people then subsequently developed a substance use disorder to the opioid to which they were prescribed. That started in the early 1990s. When we talk about the epidemic, we often talk about it in waves. The late 1990s to early 2000s is the first wave associated with the prescribing of opioids. Then in 2010, approximately, is when we started to see a rise in heroin-associated deaths. As people who had developed an addiction or an opiate use disorder to the prescribed opiates were no longer able to access them, then they may have transitioned to heroin.
Also, financially, heroin was significantly less expensive. If you were relegated to having to purchase something on the street, heroin was less expensive than buying a pill of oxycodone, so many people transitioned. Then, probably about 2013 is when we started to see the rise of these illicitly manufactured fentanyl, specifically, or now people are referring to them as “highly potent synthetic opioids,” which is illicitly manufactured fentanyl.
You started to see a rise in deaths associated with fentanyl and its analogues in about 2013. In truth, even today, that’s what’s driving the majority of the epidemic: this high-potency synthetic fentanyl that is on the street. Fentanyl and its analogs that are on the street are what’s driving the current overdose epidemic.
Then many people will talk about a fourth wave of the epidemic where, around 2014-2015, we started to see a rise in stimulant deaths. Again, more likely in the setting of concomitant opioid use. Many times people purchased what they thought was a stimulant, and it was either fentanyl or laced with fentanyl. Then you see people dying, increased deaths associated with stimulants.
That being said, when we are looking at substance use disorder, we certainly need to focus on opioids, but we need to focus on the larger substance use in general. But as physicians and other medical practitioners who are prescribing, we do need to be more judicious about opioids and our prescribing of opioids and recognition of non-opioid approaches to management of pain. There is a lot of data on non-opioids, whether it is acetaminophen or ibuprofen, in terms of adjuvant medications for the treatment of pain. We do need to look at that as part of our practice as well.
RK: It is so interesting to hear about these different waves and the provider role in some of this—the accessibility and how that has impacted what drugs people are accessing to numb their pain. Then there are these synthetic versions that might be laced in other products that people don’t realize. It is something that all of us have heard about, and in the context of diabetes care, anyone who is at risk for pain or could have pain-related complications, such as neuropathic pain, whether we can see what diabetes or other kinds of pain could be at risk for this. I appreciate you going through all the history and then also the different forms that are out there for our listeners to be aware of as well. We have covered a lot today. Did you have some other comments that you wanted?
AA: Yes, I am just going to say one thing: I would say, for people who are prescribing, if you are prescribing an opioid for management of pain, you should also be prescribing an opioid reversal agent. Whether it is naloxone or nalmefene, you should be educating your patients and their families on how to use that reversal agent, should it be needed.
RK: It sounds like that is also good for patients and their families to know about too. If their provider does not talk about that reversing agent, they should ask about it.
AA: Yes.
RK: We do that, for instance, with people who are at risk for hypoglycemia, who might be on insulin—we give them glucagon as an emergency rescue. It is different than the reversal that you’re talking about, but it sounds like they go hand in hand. Thank you for bringing that up.
As we wrap up our podcast today, might you have some parting words for people who are listening with diabetes, family members of people with diabetes who are concerned that they or their loved one might have a substance use disorder but might be afraid to step forward or might be afraid to seek resources? I wonder what you would say to them and also what other helplines or anonymous resources or anonymous call centers there might be for them to even just start getting information if they’re not ready to make that step.
AA: Things that I want to say in terms of leaving people with something.
One, addiction is not solely based on one’s personal choice or moral failing; it is a chronic disease, and there are chronic changes that occur in the brain. But like any other chronic disease, it is treatable, and there are resources and support available.
I think it is important to know that there are medications for treatment for at least some of the substance use disorders and that the evidence shows that they, at least particularly for opiate use disorder, are often first-line treatment for the substance use disorder.
Recognizing that there are multiple paths to recovery and whether somebody is taking a medication to treat their substance use disorder, whether they’re using exclusively behavioral and other psychosocial supports for treatment and of the substance use disorder, all paths can lead to recovery in terms of resources available.
The Substance Abuse and Mental Health Services Administration, typically, that acronym is SAMHSA, has resources. SAMHSA has resources related to getting assistance with treatment for substance use disorders.
The National Institute on Drug Abuse, which is the NIH Institute, has a lot of resources and education. If people are looking for more information, it has a lot of information about, particularly drug use disorders.
There is the National Institute on Alcohol Abuse and Alcoholism (NIAAA), which is the corresponding institute in the National Institutes of Health related to alcohol use disorder. They have a lot of information and education and some resource materials as well.
If somebody is in crisis, 988 is the new number for crisis. If you’ve got a family member who is in crisis associated with their substance use or potentially co-occurring mental health disorder, 988 is where you can call to get information in a crisis; information, and assistance.
RK: Dr. Alvanzo, you talked about. So many great resources. I wonder if there are any other resources that you’d like to highlight for our audience today.
AA: Yes, there is one additional resource that I’d like to highlight. The American Society of Addiction Medicine (ASAM) is the professional organization for people who are treating those with substance use disorders. In addition to being the organization or the professional society for those who are working in the area of addiction or substance use disorders, there is a lot of information and education, particularly as it relates to policy and advocacy related to substance use disorder and the treatment of substance use disorder. That is just one additional resource I would like to highlight.
RK: That sounds like a great resource; thank you for highlighting it.
Dr. Alvanzo, thank you so much for sharing your expertise today, for talking to us about substance use and substance use disorders, the different types of substances, the types of treatments and treatments for withdrawal symptoms that might be available, the importance of resource availability for people of all populations, and then really, the stigma that some might still feel or hear about and resources that people have to make that first step to seeking treatment and having treatment for this treatable disease.
We appreciate your expertise today, so thank you for being here.
AA: Thank you. Thank you for this opportunity to talk about this; it is an important issue. I am so happy to have the opportunity to come on and speak about this with you and your listeners.
RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit hopkinsdiabetesinfo.org.
We love to hear from our listeners. The email address is hopkinsdiabetesinfo@jhmi.edu.
Thanks for listening. Be well and see you next time.
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- Home - | - Episode 46: Diabetes Technologies: Insulin PumpsIn Episode 46, Dr. Kalyani welcomes Adena Goldstein, who will speak with us about diabetes technologies, specifically insulin pumps. Adena graduated from Villanova University with her Bachelor of Science in Nursing. She is currently a clinical diabetes nurse and certified diabetes care and education specialist at the Johns Hopkins Outpatient Diabetes Center in Baltimore.
Download TranscriptTranscript: Podcast 46: Diabetes Technology: Insulin PumpsDr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani, at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.
Today we are thrilled to welcome back Adena Goldstein, who will speak with us today about insulin pumps. Welcome back, Adena.
Adena Goldstein, RN, BSN, CDCES: Thank you.
RK: I thought that for today we could focus on insulin pump technologies. These have changed, haven’t they? A lot over time, in terms of the capabilities and functionalities that insulin pump devices can offer.
I thought before we dive into what these technologies are, if we could briefly talk about who might need an insulin pump and when they might be recommended by the healthcare provider for a person with diabetes.
AG: An insulin pump is an alternative way to give insulin. As opposed to multiple daily injections where you have a shot of long-acting insulin and then short-acting insulin for your meals or for correction. In the insulin pump there is just fast acting insulin and it’s just a different way to give insulin. Someone who is on multiple shots of insulin a day would be a candidate for an insulin pump.
The pumps, as you said, have changed a lot over the years. They’ve become very sophisticated. I tell my patients at every follow-up visit, “There’s something new on the market” or “Some new feature’s available.”
Generally, people who are dependent on insulin to manage their diabetes might be a good candidate for an insulin pump.
RK: It is good to know about because these have changed a lot over time, and they can offer an option that may be an attractive option for patients who are used to injecting insulin multiple times a day — four or five times a day. This is an alternative that might facilitate diabetes care and, in some ways, make it easier for the patient as well. It’s a personal choice; it may not be for everyone. As you mentioned it’s often recommended for people who are on multiple daily injections, usually a long-acting insulin and mealtime or short-acting insulin or fast-acting insulin as well. It could be type 1 diabetes, where I think we often see this discussed as an option and type 2 diabetes for those later in the stage of their disease who are on multiple daily insulin injections as well. Do you see patients with both type 1 and type 2 diabetes in your clinical practice that use insulin pumps?
AG: The majority we see are type 1, but we do have some type 2 patients as well, who just prefer that method of giving insulin. Aside from a practical, different way of giving it, there are a lot of advantages to insulin pumps.
Some of the advantages they have been shown to lower A1C levels, especially the hybrid closed-loop pumps, which I’m sure we’ll touch on later; less low blood sugar [levels]—more time in range; it helps with the dosing because it takes the insulin that they already have working in their body into consideration when they do give more insulin. The tiny increments at which you can give the insulin are so helpful because in pens you can’t go less than half a unit, and in pumps, you can be very precise. It also allows more flexibility for meals and dosing for snacks; instead of giving so many more shots, you’re just able to program the pump and tell it how much to give. Pumps can be programmed to different rates at different times of the day.
They are integrated with sensors now, based on where it predicts your blood sugar is going to be, it is going to adjust the insulin based on that. This is very sophisticated and has really helped a lot with preventing the lows and the highs. Some of the pumps also can give automatic correction doses if you are running high. It really takes a lot of the mental burden actually off of patients.
RK: Wow. It’s so amazing to hear about all the functionalities that insulin pumps can now offer. You are right, it is not just a different route of administration, but it has so many potential benefits, both clinical benefits and practical benefits.
As you mentioned—making the day-to-day management a little less burdensome for people with diabetes who take a preference to this modality of receiving insulin.
I thought the point that you mentioned was an important one to emphasize was that in an insulin pump, it is the fast-acting insulin. Only one type of insulin is given and hat can be a little confusing for patients who are used to having a long-acting insulin and a fast-acting or mealtime insulin injection. At this time, primarily insulin aspart (Novolog) and insulin lispro (Humalog) are given through the pump.
You mentioned so many different types of functionalities of the pump. Can you describe for us, for someone who hasn’t seen an insulin pump, what does it look like? What can people expect when we’re talking about insulin pumps?
AG: There are different types of pumps. The basic idea is that there is a little catheter that is placed under the skin, and it’s connected to the insulin pump. Some have tubes that connect to the actual pump, and some are tubeless, which are connected more to a pod. Insulin is fed through the catheter and then given to the patient that way, under the skin. It’s given continuously; it drips little bits of fast acting insulin all the time, which mimics that shot of long-acting [insulin] and it also mimics what a normal pancreas would do—a little bit all the time.
Then when you go to eat or correct a blood sugar, you enter that into the pump and it gives what we call a bolus of insulin through that cannula under your skin. That cannula is changed out every few days. There are some that can be changed every seven days, but typically it’s every few days. To give the area [a break], you need to move it around just so you have good absorption of insulin.
RK: In terms of the size of an insulin pump and the size of the catheter, could you give us a sense of how big we’re talking about here or how small?
AG: There are different sizes of the catheters. They are as small as 6 millimeters. There are some that are angled, so those are longer, those can be 13 millimeters. There are steel cannulas that you leave in — you don’t remove it. That is a different type, but those are about 6 millimeters as well. The pumps, vary in terms of sizes. They’re about the size of a deck of cards, maybe a little smaller.
RK: That gives us a good sense to visualize what we’re talking about. They’re really not that big at all; 6 millimeters for the catheter, the size of a deck of cards — maybe even a thin deck of cards, if you will, for some of the newer pumps. I think it’s important to recognize that these are not huge devices as they might have been when they first came out on the market, many decades ago.
But [these are] really portable devices that have a cartridge for the insulin that is infused continuously. An insulin pump usually infuses the catheter into the area right beneath the skin, the subcutaneous tissue. So it’s pretty remarkable when we think about this technology, isn’t it?
AG: If you see pictures of the first insulin pump, it’s a big backpack, and now they’re so small, they’re very discreet. Some of them can be managed through a smartphone. A lot has changed over the years.
RK: I can’t imagine the backpack pumps now that we know how small they’ve become. But technology evolves so rapidly over time. It’s important to recognize how far we’ve come.
You mentioned different components of the pump. The actual pump, which could be the size of a deck of cards or thinner, the catheter through which the insulin can be infused. Then you also mentioned using a phone. Can you talk about when that might be used? Is that for the CGM part of it, the continuous glucose monitor part of it? Or can that actually control the insulin pump?
AG: There are a couple pumps on the market right now that you can actually control the pump from the phone — you can give your boluses from the phone. There are times, [when] you have to deal with the pump; when you refill it and to cancel alarms sometimes. But a lot of the day-to-day functionality you can do directly from the phone. There are some pumps that are only managed from a phone. That’s a big component of that type of pump.
RK: Wow. That is just so amazing to have these different devices communicating with each other and that so much can be done even from the phone. This makes it, in some ways, less noticeable for someone who might be at work or in a professional setting who might need to give themself a bolus before they eat or change their rates for any reason. That they could do that from the phone, is pretty remarkable to hear about. Where do people wear the insulin pumps? Where on the body do people wear those?
AG: The insulin pumps are generally in areas where you would give insulin — same spots. The tubed pumps are generally in the midsection of a patient’s abdomen, lower back, upper part of the buttocks. Because that tube or the pump does need to clip onto something, in a pocket or, something like that. It can be worn [on] other places, but generally those are the more typical places we see. Then there’s also tubeless pumps, which offer a little bit more in terms of flexibility of where you wear it because it doesn’t have that tube or that clip that needs to be clipped on somewhere. People wear those on the back of the arm, on their legs, also their stomach. Again, any place where you give insulin.
RK: It sounds like there’s really a lot of options in terms of where a pump can be worn and also in terms of the types of pumps. I wonder if we can now shift a little bit to talking about the different kinds of pumps that are available on the market and how an individual who’s considering this technology might try and decide which pump is best for them.
Clearly what’s covered by their insurance is an important factor. But assuming that there are options for coverage, how could they best decide what pump is best for them?
AG: Every pump has different features, and I always tell patients “It’s like buying a car. Which feature is the most important to you when you’re looking at a purchase like this?”
We can go through the different pumps and talk about some of the key differences between them. Again, for some people one factor is like number one priority and for other people it is not so important. It really is so individual.
We can start with the tandem pumps. There are currently two pumps on the market. The Tandem, t:slim X2 pump; it’s a touchscreen rechargeable pump that is updateable. As new technology comes out, you can just plug it in and get the updates. That’s pretty common nowadays, but years ago, as soon as you got the pump it was basically outdated because new technology was coming out so quickly. It’s updateable, which is great for new algorithms, new sensor compatibility, different things like that.
This pump is currently compatible with the Dexcom G6 and Dexcom G7, as well as the Freestyle Libre 2 Plus. It adjusts the basal rates and gives auto corrections based on where the blood sugars are predicted to be with the sensor integration.
This pump does allow you to bolus from your phone. It doesn’t allow you to manage the whole pump from your phone, but it does allow you to bolus from your phone. If you’re at work and you’re at a meeting, you don’t want to take out your whole pump. You could just do it directly from your phone.
The other newer tandem pump that is available is called the Tandem Mobi. This pump is about one third of the size of the regular t:slim X2, and it is completely controlled from an iPhone. It can be worn with a traditional long tube, or it can be worn with a 5-inch tube and a little pocket that it can sit in. This pump holds 200 units as opposed to the traditional t:slim X2 that holds 300 units.
For some patients who go through a lot of insulin, that might be an important factor. For some people, they really like the idea of doing everything from the phone. Other people don’t like to use their phone at all. It gives different options for different types of people and what they like. The Mobi has the same algorithm as the t:slim X2, it is just a different form factor.
RK: There are so many exciting developments, as you’ve mentioned with these newer models. I was wondering if you could talk a little bit more about how this automated insulin infusion works and how does the pump predict what’s going to happen. I’ve heard about pumps automatically shutting off infusions at times too, if you could talk a little bit about that as well.
AG: The tandem pump, for example, will look 30 minutes ahead based on, the Dexcom or the Libre reading, the sensor reading and based on how much insulin is already working in your body. It makes a decision every five minutes how much insulin to give you. I described the basal rate, like a dimmer switch, it goes up and it goes down based on where those blood sugars are trending. It could also, like you said, shut off so that pump, the tandem specifically, tries to keep you between 112.5 and 160 mg/dL, but it’s looking 30 minutes ahead. If it thinks you’re going to be above 160 mg/dL in 30 minutes, it’s going to dial that basal rate up. If it thinks you’re going to be below 112.5 mg/dL, it’s going to dial it down. If it thinks you’re going to be above 180 mg/dL, it’s actually going to give you an auto correction, if you haven’t had a bolus in an hour, automatically about 60% of what a correction dose would be. If it thinks you’re going to hit 70 mg/dL in 30 minutes, it’s going to just shut it off.
But it’s making that decision every five minutes. You might be shut off for 10 minutes and then it goes right back on — all automatically. We see these pumps really shine particularly overnight when people are sleeping because they need different amounts of insulin, night to night, and that’s when they’re sleeping and not paying attention to their diabetes. We really see a significant benefit, and one third of a patient’s day is sleeping. We do see a lot of improvement in the A1C because of that. Patients really enjoy waking up in a good range every morning.
RK: The automated basal setting really does have so many advantages like you talked about, and I know we’ll talk about other pumps that have a similar feature as well.
There are limitations though, aren’t there, which is why patients still need to bolus their insulin before meals. Could you talk about times where the automated setting may not be able to keep up with changes in glucose?
AG: During times of illness sometimes we would put someone out of the automated system and back into manual mode, depending on the pump. Or maybe we would create another profile for them with more aggressive rates, if they needed more insulin during a time of illness. Or if they were on steroids for whatever reason, you have that option. Also, during pregnancy sometimes we will take patients out of automated; for some patients we keep them on; in some patients we do half and half. Again, it’s very dependent on the patient.
RK: I agree. Especially when glucose levels are changing rapidly, for instance, after meals or those kinds of situations, that can take a while for the automated setting to catch up and for some patients who may need to be reminded that getting that mealtime insulin is just as important because the automated rate can’t keep up with the changing glucose levels. It still does require some effort from the patient as well.
AG: Yes, the, patients do need to input good information in order for the pump to work well. People hear automated and sometimes just stop — hands off. But really you do need to input all that. Your meal information, the blood sugars will pull in and give you appropriate doses based on that information.
RK: That’s an important point to keep in mind for all of these pumps. We talked about the Tandem pumps. What other pumps are out there on the market?
AG: There is the Medtronic pump. Medtronic has been around for a long time. Their current pump on the market is the 780G. This pump does have adjustable targets down to 100 mg/d. It is updateable, just like the other Tandem pump I mentioned before. This pump does use real batteries.
It’s integrated with their Guardian sensor. It does require one calibration to go into the automated smart guard — what they call it. This typically is done about once a week for most patients. This pump has a seven-day infusion set option, which is unique. The other infusion sets are supposed to be changed every two to three days, but this one can stay in for seven days.
This pump also has what they call meal detection technology where it detects the rising rate of change in the glucose after a meal, and then we will deliver more aggressive correction doses up to every five minutes to deal with that rise post-meal.
RK: That’s really interesting. We haven’t yet talked about the different pump settings that an individual with diabetes should be aware of. I wonder if we could just pause here to talk about the settings that a person with diabetes should be aware of. You mentioned correctional insulin, but I realized we hadn’t talked about the different components. Can you just briefly talk about those Adena?
AG: Yes. So, there is a basal rate, which is a little bit that’s given every few minutes, and that can be programmed for different times of the day. All of the settings really can be programmed for different times of day.
There is an insulin to carbohydrate ratio — how much one unit of insulin covers how many carbohydrates that will be programmed in.
As well as the correction factor where one unit will lower your blood sugar, a certain number, that is also programmed.
The target is also a number that we can program into the pump. For some pump there’s a correct-above number as well.
Then there’s active insulin time. Active insulin time is a setting that we can sometimes change a little bit. It’s not necessarily what the actual scientific studies, in terms of how long insulin will last in a person’s body, but it’s how the algorithm uses that number and that will guide how often a correction dose can be given and how soon a full correction dose can be given.
RK: Usually, what is a number range for that?
AG: That’s typically three to four hours for most people. Some pumps are programmed at five hours for that. It just depends on the patient, and depends on the pump.
RK: And how about the carbohydrate ratio you mentioned? What are some examples of a range that people might be in for that?
AG: That could be something like one unit for 10 grams. Again, very dependent on the patient, and their insulin sensitivity. One unit for 15 grams, someone who’s very resistant might be on, one unit for five grams, or four grams.
RK: Yes, there’s a broad range, but I think that does give a sense of what we’re talking about here in terms of carbohydrate ratio.
Then you mentioned a correctional scale. What are some examples of a correctional scale that might be given to a person on a pump?
AG: A correction factor could be, let’s say 50 units. One unit will bring down a patient’s blood sugar by 50 or is expected to bring it down by 50. It uses that number as well as the target to figure out how much to give if a person’s blood sugar’s high.
The pumps also do all of the math for you. It’s good to know how to do it, the manual way in case something happens. And everyone always needs to have a backup plan in case — it is a device, things happen. You always need to have your backup plan of how you’re doing it currently, or back to injections.
RK: You mentioned quite a few pump settings and also that now the pumps can do a lot of calculations for the individual, even though it doesn’t replace the need to be educated about it and to know about it. Once the basal rates are programmed and these other rates are programmed into the pump, with the newer technologies, what do the individuals with diabetes have to do? What do they have to input in the pump?
AG: They input their carbohydrates that they’re eating. For some of the pumps they just announce when they are eating, which we’ll talk about soon, but they still need to input their carbohydrate intake to let the pump know this is what I’m eating. The pumps will automatically pull in that blood sugar to add the correction dose along with their mealtime dose.
RK: Then once that’s calculated, does a user have to do anything to actually give that, what we call, bolus dose?
AG: Yes, there’s usually a couple confirmations because we want to make sure that they really want to give the right amount. I always tell people, especially once you get used to it, “You go really quick, really fast, and it’s easy to press, an extra button, or skip the decimal point — always double check when it has that, you double check to make sure you’re giving the right amount that you intend to be giving.”
RK: It’s pretty remarkable that now that we have the integration with many of these newer pumps and a continuous glucose monitor that feeds the glucose levels. As you mentioned [with] the older pumps, often patients had to input two things — the carbohydrates they’re eating and the number before a meal. But now that second part has been largely relieved by the integration of pumps with CGMs. While patients still have to input the carbohydrates they’re eating, much of that additional information is already fed into the pump, which is pretty amazing.
AG: Yes, it really is.
RK: We digressed a little bit to talk about the different types of pump settings that an individual should know about — just broad categories. But going back now to the Medtronic pump that you had talked about, were there any other features or any other models that you thought would be important to talk about?
AG: That was the Medtronic one. The next pump I’d like to introduce is the Omnipod 5.The Omnipod 5 is a tubeless pump. That is integrated with the [Dexcom] G6 and the G7 sensors. It takes the blood sugar readings and adjusts the basal rate only. This pump doesn’t give auto corrections, but it does adjust that basal — like that dimmer switch, we talked about earlier.
ecause it’s tubeless, it has a controller, a separate controller. But it is also integrated with Android apps and recently the Apple app came out.
The algorithm on this pump is adaptive, so as your insulin needs change and your total daily dose changes, it will change the rates as well. With this pump, the user can’t adjust basal rates during automation.
If you make an adjustment to the basal rate, it won’t affect any changes in automation. This pump is also unique because it is a pharmacy benefit. So, I don’t think I mentioned earlier, but [with] the traditional tube pumps, you’re locked into your warranty for four years for commercial insurance and five years for Medicare (in the United States). Meaning the insurance will pay for a new one every four or five years. But if it’s a pharmacy benefit, patients can go on that at any point regardless of their warranty status on a traditional pump.
RK: That’s really interesting. How is that determined? Whether it’s a pharmacy benefit or not? Does that vary by the type of pump or the type of insurer?
AG: The Omnipod 5 is marketed exclusively as a pharmacy benefit. This pump will only be available at the local pharmacy or mail order pharmacy. Occasionally some of the other pumps, or parts of it, the supplies, can be put through pharmacy, but the actual device is put through as medical typically.
RK: That is interesting, and it has implications when patients are looking at upgrades or looking at newer models and deciding what kind of benefit makes sense for them. I appreciate you pointing that out. You mentioned that it was tubeless. How does the insulin get infused if it’s tubeless?
AG: There’s the small catheter that comes out of the little pod, and that’s what goes under the skin. It sits directly on the skin. You can’t give insulin from the pod. Again, it needs to be done either from the controller, which is like a remote — it looks like a phone or from an actual app on your phone.
RK: That is really interesting and a different type of pump route of administration. That’s important to point out as well. What other pumps are there out there?
AG: The last pump I wanted to introduce is called the iLet. This is a different type of concept pump. This pump works with the Dexcom G6 and G7, and the Libre 3 Plus.
This pump is different because, you know all the settings we were talking about before — this pump does not have those settings. The only setting you program into the pump is the patient’s weight.
For this pump, you don’t need to enter the precise carbohydrates that we talked about before — you’re just announcing your meals. You do need to be carbohydrate aware, so you need to be able to identify a carbohydrate and be aware of if you’re eating more than your usual amount, less than your usual amount or your usual amount. That is what you tell the pump and it will figure out exactly how much to give you. It takes the numbers out of diabetes management, which is a novel approach.
This pump has no real backup plan. If you’re not wearing the sensor, there’s no manual mode like we talked about before, because there are no settings that were input initially. Patients need to be very conscientious to always have their sensor on with this pump.
This pump is good for people who may not necessarily want to micromanage their diabetes — just announce what they need to announce and let it be, you can’t give corrections at other times.
This pump holds 180 units, so it’s a little bit less, but they do have some prefilled cartridges that we will [or] can sometimes get authorized for people to put in there, so it’s easier to bill and just replace the insulin. But it is the smallest amount of volume that’s in a pump.
RK: That’s so interesting that this model of pump doesn’t require carbohydrate counting the way the other pumps do. I know for some patients it can be hard to count the carbohydrates. Especially if meals are unpredictable or not being prepared at home, or even if they are being prepared at home, if there are ingredients that are not as familiar. So I can understand how this could be an option, particularly for people who may not be as well versed in exactly counting the amount of carbs or have challenges in doing that on a consistent basis. But it seems this is more qualitative, isn’t it? If it’s more than you usually eat, less than you usually eat or the usual amount. Given that it doesn’t seem to be as quantitative (in terms of numbers), how effective is it at really keeping the blood sugars in check?
AG: The algorithm is very strong and works really well if you don’t try to outsmart it. If you try to, give meals that don’t exist or if you forget to announce your meal — those are things that could mess up the learning and the algorithm. But if you do what you’re supposed to do with it and you’re pretty consistent, then it is a very effective way at managing blood sugars.
RK: Thanks so much, Adena, for going through those different types of pumps. Particularly the newer models within each manufacturer that are currently available. Given that there are so many great options out there, how do people decide which pump is best for them?
AG: Some people, the tube versus tubeless is a factor. Some people, the size is a factor. Some people, the phone compatibility with the apps, like we talked about, is a big factor. For some people it’s the algorithm, which algorithm is, more aggressive and will help them with their blood sugar. Particularly with their management habits and eating habits.
It really is so individualized. Your provider might have some suggestions and may guide you to one based on where they think you would do well. But ultimately it really is a patient preference as to which type of model they would like to move forward with.
RK: You mentioned not only the practical benefits of relieving some of that mental calculation and mental burden compared to being on the multiple daily insulin injections, but also some of the clinical benefits as well, not only in helping to manage the high blood sugars, but also the lows — I’ve definitely seen that as a benefit with some of the newer technology you’re talking about, the infusion rates can stop automatically to prevent lows, especially overnight when people are sleeping.
However, we know that insulin pumps aren’t for everyone. So, I wonder if you could just talk briefly about who might decide not to wear a pump and what other factors might contribute to that.
AG: There are some people who don’t want to wear anything on them or have a physical sign of their diabetes that’s visible. But again, a lot of them have become so much smaller and more discreet that I don’t hear that as often. Generally, the clinical benefits are so profound that a lot of people can move past that, to at least to try it. A lot of the different pumps, they allow you, even the ones that get processed through your medical, they do have a return policy. If you really are not satisfied with it, they will take it back and refund your insurance. I really encourage patients to try it and, see if it’s something that they can get used to.
Other patients who may not be a good candidate are patients who use a lot more insulin than, if they’re using 300 or more units a day, they would be changing out the pump so frequently. They also might not be a great candidate for a pump.
RK: It’s definitely an individual, personal decision regarding these pumps, but a discussion that’s important to have at some stage of management regarding the options that are out there.
Are there any activities to avoid while wearing a pump? How does it impact daily life at all? For instance, showering or exercising. What do people do with their pump?
AG: The tubeless pump, the pod, is always on. You don’t take that off. You swim with it, you shower with it, you exercise with it — it’s always on.
The traditional tube pumps while they’re water resistant and watertight; we typically don’t recommend swimming with it, because you never know when there’s a little crack in it and you know it’ll break if you go in the water. I tell people “it’s okay if you get wet outside in the rain or you get sprinkled by a hose, that’s fine.” But we don’t generally recommend wearing it in the water.
There is a little connector piece where you can disconnect it for showering and going in the pool, for short periods of time. Without the pumping connected you’re not getting that fast acting insulin. You don’t have any long acting insulin in the background. Your blood sugars can go very high without any insulin in the background. Your basal rate is stopped if you remove the pump for those activities. You have to be mindful, if you do swim all day to go back and forth with your pump to reconnect, give yourself some insulin and then go back out. But generally, it’s something you sleep with, you figure out how to get it to work for your lifestyle.
RK: I think that’s the key is that you figure out how to make it work for your lifestyle. But it’s great to know that showering, water resistant technology, is not a problem. And then different kinds of activity, like you mentioned, swimming clearly is an exceptional example where you might have to take it off and appreciate you mentioning that.
It’s important that if you’re ever disconnected from your insulin pump or if there’s a pump malfunction that a person with type 1 diabetes particularly and in person with type 2 diabetes, who was previously on multiple daily injections, may not or probably does not produce insulin on their own. They may need to take some insulin injections until the pump, or device is restored.
Then exercise in general. I think one of the great features about these pumps is you can have an exercise setting where you can maybe reduce your infusion rate by a set percentage, let’s say 50%. I know I have some patients who do disconnect the pump during times of exercise because they know their sugars go lower during some kinds of exercise.
It is just important to have that discussion, as you mentioned with your healthcare provider to know if there’s any other precautions that are needed, such as snacks, taking snacks, or injecting the insulin as well. But again, it’s about adapting to it, as you mentioned, which I think is the key.
Given that technology is changing so rapidly, how do people with pumps keep up with updates? Do, how do they find out about them? Does the manufacturer tell them when there are updates? Do they have to update the software every now and then? How does that work?
AG: They will be notified by the manufacturer if there’s any sort of update they need to do to keep their pump in good, healthy working order and as new technologies come out, so they can update their pump.
RK: We’ve talked about a lot of different types of functionalities of the pumps. We’ve talked about how far the technology has really come over the last few decades from backpacks to really now just a deck of cards, in size. What is on the horizon? What do people mean when they talk about closed loop systems and artificial pancreas? Could you just talk about that briefly? Where are we going?
AG: In the future the goal would be less patient integration or less patient interaction with the pumps. Right now, the insulin will bring the blood sugar down, but in the future if pumps could also have glucagon, for example, in the pump that would treat the low blood sugars.
The idea is, with iLet, having no carb number inputs takes more of that patient effort out of the insulin pump management. More announcements or like the Medtronic [system] can detect the meals; to have more sophisticated algorithms to manage.
Ideally if a patient could just wear a pump and not have to bolus, that would be, the best. It’s exciting, the things on the horizon. Some parts move quickly, and some parts move slower. We’ll see how the next few years play out.
RK: It certainly is an exciting time. And as you mentioned, a true closed loop system would require no effort from the patient. They wouldn’t have to press a button to give themselves additional insulin and a bolus for meals. They wouldn’t have to pay attention to the numbers, although we would hope that would still happen. But really it would be like having your own pancreas. You don’t think about it on a day to day or minute to minute basis. Really that’s where the technology is heading. It will be exciting to see as we get closer and closer to that the developments to come.
In parting Adena, I wonder for our listeners out there who might want to talk about the option of an insulin pump with their healthcare provider, or maybe they’ve had that conversation already with their healthcare provider and they’re reluctant to proceed with trying the insulin pump. What would you say to them?
AG: I really recommend them to just try it. I know people are very comfortable with the way they’ve been doing things and it’s always scary and nerve wracking to try something new and to shake things up. I always tell people if they are willing to try it, to do it at a good time in their life and not when they’re moving or starting a new job, at a good time when they could, invest into it and invest in learning it. Because there is a learning curve. It’s a different way of doing it, but after a while, like with injections, you do get used to it—it becomes second nature.
I think patients really do see a huge benefit, clinically. Their blood sugars just — when I see before and after pictures of patients, they go from injections to automated closed loop pumps, it gives me chills. You just see a lot less variability, a lot less lows, and smoother blood sugars. Very often patients just feel better with that smoother blood sugar range.
RK: That certainly is something to have chills about, to think about how much these technologies can impact the person with diabetes. Particularly the population that we talked about, who could really benefit from these — really having that conversation with the healthcare provider about whether it could be an option for you.
Thank you Adena so much for being here and educating us about all the different types of insulin pump devices out there. I’m sure there are going to be many more developments in the months to come, and we look forward to hearing about those too in coming episodes. Thank you so much.
AG: Thanks for having me.
RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit hopkinsdiabetesinfo.org.
We love to hear from our listeners. The email address is hopkinsdiabetesinfo@jhmi.edu.
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- Home - | - Episode 45: Diabetes Technologies: Continuous Glucose MonitorsIn Episode 45, Dr. Kalyani welcomes Adena Goldstein, who will speak with us about diabetes technologies. Adena graduated from Villanova University with her Bachelor of Science in Nursing. She is currently a clinical diabetes nurse and certified diabetes care and education specialist at the Johns Hopkins Outpatient Diabetes Center in Baltimore.
Download TranscriptTranscript: Podcast 45: Diabetes Technology: Continuous Glucose MonitorsDr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani, at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.
Today, we are thrilled to welcome Adena Goldstein, who will speak with us about diabetes technologies. Adena graduated from Villanova University with her Bachelor of Science in Nursing. She is currently a clinical diabetes nurse and Certified Diabetes Care and Education Specialist (CDCES) at the Johns Hopkins Outpatient Diabetes Center in Baltimore.
Welcome, Adena.
Adena Goldstein, RN, BSN, CDCES: Thank you for having me. I’m excited to be here.
RK: We are thrilled to learn from you today about the latest in diabetes technologies. This is increasingly getting attention as we have more and more technologies available for people with diabetes.
While it has been life-changing for so many people, it can also make the management seemingly more complicated. We’re hoping you can break it down for us, in terms of what people with diabetes may want to consider as they’re thinking about these technologies and how to facilitate the smooth integration of these technologies into their diabetes care.
Perhaps we could start with continuous glucose monitors, could you tell us, what are continuous glucose monitors?
AG: Continuous glucose monitors, also known as CGMs, are a little device that is worn on a patient, and it has a little filament that goes just beneath the skin and measures the glucose in the interstitial fluid every few minutes. Then there is a transmitter that sends the readings to a device: it can be a phone; it can be a separate receiver; it can be a smartwatch; it can be an insulin pump. There are a lot of different ways that it can be used. That provides data every few minutes regarding blood sugars.
I always tell patients who are transitioning to them that it’s like treating diabetes with your eyes open versus your eyes closed.
When you use a glucometer, you’re pricking your finger, and it is really a surprise whenever you get that number—you don’t know if it’s going to be in the good range, a little high, or a little low—but with a sensor, because you’re getting so many readings, you have a sense for where the blood sugars are going. In addition to the number that you get from the CGM, you also will get a direction arrow showing where your blood sugar is going. It helps you plan what you’re doing next, how you’re going to give your insulin or treat with food based on where that arrow is going.
RK: Sounds like the CGMs just really have changed the day-to-day management for so many people with diabetes. You mentioned some of the functions—the trend arrows and the alarms—that we see with CGMs. In your experience, having worked with so many people with diabetes in implementing these into their day-to-day care, how do most people feel after using these continuous glucose monitors? Especially those who’ve been pricking their fingers for a long period of time?
AG: There are very few people who actually like to prick their fingers. Most people are very happy to put their meter aside and use it very sporadically. People still need to have a meter because things can happen with the sensor, or sometimes there can be an issue with the prescription. So, we are not getting rid of meters completely at this point, but patients usually really welcome having that data without having to prick their finger. The sensors have become so much more accurate, smaller and more comfortable over the years that people really wear CGMs all the time. Years ago, people wore them sporadically; they’d be on and then off of them. Now people have become so reliant on CGMs for their day-to-day management of their diabetes.
RK: Technology is great—we know it’s not for everyone, and it really is an individual or personal decision on whether you want to use them. But it sounds like the CGM technology itself has become not only smaller but also smoother to use. Have you been finding that people have difficulty keeping the sensors on? Or are there some people who just aren’t interested in it? What has your experience been?
AG: You have to get used to having so much data in your face all the time. I usually tell people, at the beginning, for the first few days, to just watch it like a movie. You are seeing numbers that have been happening; you’re just unaware of them when you are pricking your finger two, three, four, five, or six times a day. You don’t see all the numbers that you see with the sensor.
For some people, that’s okay; they can get past that. But for other people, there is a small portion of the population that just so many numbers, all the time, can make them anxious. They’re worried about them, or they may react to them prematurely, the numbers and the alerts. We also don’t want to set the alarms tightly because we don’t want them to be going off all the time.
We want it to alert the patient when there’s something that needs to happen. If it’s going off more than it needs to, some patients will just not like it because of all the alerts.
RK: It is great to have all the functions, but they need to be used within the appropriate context, and having a device go off every few minutes. If the alerts for high glucose, for instance, are set at a value that’s within a range where the sugar might vary, it is probably not as helpful as really setting an alert for a number where we would be very concerned.
The educational component of it is so important. What you were saying is that we don’t want to make people more anxious with more data. If you have well-managed diabetes, perhaps you’re on just one pill for type 2 diabetes, and you’re otherwise doing great; perhaps having all those numbers might be more overwhelming than is needed. Really, the individual context is so important in terms of the goals of care. What are the continuous glucose monitors really being used for? What are some of the reasons you’ve seen them being used in people with type 1 or type 2 diabetes?
AG: Sometimes we’ll prescribe it for patients if they let’s say, [have] type 2 [diabetes] and are on multiple medications, still not at goal. Sometimes we will prescribe a CGM, and it teaches them a lot about their lifestyle, their food choices, and their exercise. If someone knows their blood sugar is high going into lunch, they might make different food choices than someone just not knowing what their blood sugar is and just going with how they feel.
It teaches people a lot about their diet. I’ve had patients who think their daily breakfasts of oatmeal, or whatever it is for them, is really good for them, but then they put a sensor on, and they see that their blood sugars don’t react well to that. Then they make adjustments—here’s a non-medication intervention that sometimes really impacts the A1c and the overall blood sugar control.
RK: It certainly can be insightful for people to see how their foods and their activity patterns impact blood glucose during the day. I know, even people who are healthcare providers who have worn CGMs just to understand themselves how these patterns can vary throughout the day so that they can also educate patients about it too.
We do have these professional CGMs that even if you don’t wear one at home, you can wear it for—let’s say, a week or two—to get some insight into daily patterns. What we’re really talking about here today is those continuous glucose monitors that are worn every day by the person at home, the personal CGM. You mentioned with type 2 diabetes, it could be someone on multiple diabetes medications who’s having wide fluctuations in their blood sugars, highs and lows. I found them very effective for people who might have lows overnight, for instance, or are fearful of lows and really benefit from having the alarm go off when the sugar is too low. What has your experience been?
AG: That’s really where the sensors shine, having the alerts for patients. Someone who has had diabetes for a very long time, type 1 specifically, sometimes they lose their sense of feeling lows and they can just not have them. Without a sensor alerting them, particularly people who live alone, they wouldn’t necessarily know they were low until it was too late, and they were having a severe reaction. Having those alerts is so helpful. There’s also now an alert that goes off before they get low, so they can prevent lows. We don’t want them to just get low and know they’re low. We want them to prevent the lows and treat them early with a little bit, just so they can be in a safe range.
RK: I agree. Thanks for mentioning that unawareness. With the hypoglycemia unawareness, it’s especially helpful in people who might not feel symptoms anymore of lows. When we’re talking about lows, we’re usually talking about numbers below 70. So, for our audience who’s wondering what we’re talking about, when do you usually set the alerts for the lows? What number do you usually set alarms for?
AG: It depends on the patient. So that’s very individual, which is what we were talking about before, setting them not too tightly, but it depends on the patient and what their normal blood sugars are at the time that we start. I always tell them they could always adjust it to be notified at different numbers, but you want to be notified at a point where you would need to treat or do something.
It does depend on the patient; some older patients want to be notified at 80; some younger patients just want to be notified at 70. Again, there’s a low alert soon, which looks 20-30 minutes ahead and says, “Hey, you’re going to be low soon.” That could happen at any number—that could happen at 100. It’s just looking ahead at what it thinks the blood sugar is going to do.
RK: That’s such a great technological function that it can do this predictive algorithm to anticipate the low before it happens. We know that CGMs also have a little bit of a time lag, don’t they, compared to blood levels? Can you talk a little bit about that too?
AG: The sensors measure the glucose and the interstitial fluid. Compared to the blood glucose, it can lag about 5–15 minutes behind where the blood is. What I always teach patients when I train them on their CGM is that they need to keep that lag time under consideration when they’re treating their lows, for instance.
If someone has a low blood sugar [reading] on their glucometer and they eat some glucose, it takes about 15 minutes for the meter and for their blood to catch up to that. If the CGM is 5–15 minutes behind that, it may take a full 25–30 minutes before they see that arrow start changing.
Sometimes patients will just keep eating because they see their number’s low on their monitor, but we really have to tell them, “As soon as you take enough and you start feeling better, just let the sensor catch up.” There’s a learning curve with that, but they do get used to how to use that number.
RK: That’s a really important point. Also, another reason—even though we’re talking about the continuous glucose monitor and the sensor today — to have that finger-prick glucose meter to get an even more immediate number. Even though there’s still a little bit of a 15– minute lag there too for the sugar to bounce up. But with the sensor and the CGM, that’s also another 15–20 minute lag compared to the blood value. That’s a hugely important point that it’s based on symptoms. When you’re feeling better from your low and also starting to see the numbers go up on the glucose meter too.
AG: We see that lag mostly when the blood sugar is moving quickly. When the blood sugar is steady, there shouldn’t be that much of a difference in terms of the discrepancy of the numbers. But if you just ate, your blood sugar is going to be leading, and then the sensor is going to catch up to that afterwards. That’s where we see the biggest discrepancy.
RK: That makes a lot of sense. Since we’re talking about discrepancy, one of the questions that I often get is how accurate is a continuous glucose monitor compared to blood readings? What do we know about how accurate continuous glucose monitors are, especially at extremes of blood sugar, such as very low or very high?
AG: In the regular ranges, they’re very accurate. The FDA has said you can dose insulin based off of these numbers. So they are very accurate. At the extreme lows and highs, there’s a bit more of a margin of error. Those are some times where you may want to take out your meter just to double-check what it is. We always tell people, “If the number doesn’t match what you think it’s going to be, also test with your blood.” Or sometimes the monitor will give you a number, but no arrow, or no number. If it just says high or low, those are times that you also would want to verify with your glucometer.
RK: What about sensor wear? Some of the sensors last 10 days; some last 14 days. Are they just as accurate near the end of their lifetime as they are at the beginning?
AG: The first 24 hours of a sensor are generally the least accurate out of all the subsequent days. So, as you wear it, the longer you wear it, the more accurate it does get. On that first day, if the numbers don’t quite seem right, that might be an opportunity to prick your finger to check. But in general, even that first day, it’s still pretty accurate.
RK: I’ve heard of some studies where not all sensors necessarily read to the full 10 to 14 days. Have you seen that in your clinical experience in terms of the accuracy near the tail end of that time period?
AG: I think it depends on the patient. I have some patients that have no problems ever; they’ll last the whole time without any issues. Some people will say it doesn’t quite last the full amount of time for them. I’m not sure if that’s related to their activity level, to how it was placed originally, or to the location where it’s worn. I’m not sure.
RK: I think it’s an interesting question because, like you said, it depends on the individual. I think the main point to keep in mind is that it’s a tool—the CGM is a tool. If there’s any suggestion of a discrepancy or that the accuracy might not be as you would expect, check the numbers with a finger stick just to make sure or to change the sensor if needed.
AG: I also tell people that “people may feel very comfortable with their meter, and there are discrepancies within meters.” If you take different meters or test on different fingers, you’re going to get lots of different numbers. So, you’re really looking for patterns when you’re getting these alerts.
There is a margin of error with the meters, but there’s a similar margin of error with the sensors. The meters also have the user input: Are the patient’s hands clean when they take the blood sugar reading? Are they dry? Have the strips expired? Were the strips left in the car?
There are these other human factors that could affect the blood sugar reading. So people feel very comfortable with their meter—it is a great too— but the sensors also are very accurate as well.
RK: That’s great; since we are talking about the continuous glucose monitor and the sensor, perhaps you could just break down the anatomy for us. What are the components of a continuous glucose monitor? You mentioned the sensor; what is a sensor? What is a transmitter? When can a mobile device or cell phone be used? I wonder if you could just talk about the different components that make up the system.
AG: The sensor is inserted with an applicator. Some of the sensors are as small as two pennies stacked on top of each other; they’re each a little bit different. You wear the sensor on your skin; it has an adhesive patch that it sticks to. There’s a small filament that goes right beneath the skin; it looks like a thick eyelash, and that is what measures the glucose. Part of the sensor has a transmitter, which then sends the data to a device.
RK: I really like the way that you described the thickness of the sensor and then also the filaments, the tubing that goes underneath to read the glucose in the interstitial space. As you mentioned, that sensor also has a transmitter that transmits that glucose number to a receiver, which could be either its own receiver or it could be on a cell phone. Where do people usually wear the sensors? Where do you tell people to wear them?
AG: Sensors can be worn in a variety of places. Some are FDA approved; some are not. Common places are the back of the arm, abdomen, and thighs.
RK: Yes and it is personal preference, where people decide to place a sensor.
AG: Generally, people will start with an area that’s FDA approved. Then if there’s any issue, they’ll talk to their health care provider about trying alternate sites.
RK: Then how often do the sensors need to be changed?
AG: Depending on the sensor, some get changed every 7 days, every 10 days, every 14 days, or every 15 days. There’s even an implanted sensor that gets replaced every year now. There are a lot of different options.
Going back to the placement of the sensor, I always try to guide people away from placing it directly where they sleep. There’s something called a compression low that can happen if you sleep directly on the sensor. It will look like your blood sugar is fine, and then all of a sudden, you’re at an urgent low. It’s because that fluid beneath the skin is getting compressed where you’re sleeping, and it looks like you’re low when you’re not actually low. I try to tell people to just avoid placing it if they sleep in one specific spot to just avoid that area.
RK: That’s a good tip and important to consider when people are thinking about where to place the sensor. Especially if it’s in the arm, when people are side sleepers, that might be something to think about when you’re placing it there. Especially if you’re worried about nocturnal lows, it may be hard to know if it’s because the sensor is being compressed or if it’s a true low. That’s a great tip. Given that these sensors are changed anywhere between 10 to 14 or 15 days, how easy is it for someone to change their own sensor at home?
AG: The applicators for the insertion have become so much easier over the years. Most patients don’t even feel it going in. It’s just quick; the little needle inserts the sensor, and then the needle is retracted, and you’re just left with the sensor. So, it’s really easy; they’re generally one-handed button pressing. Occasionally people will have a loved one or caregiver help them with it if they want to wear it somewhere they can’t reach. But generally, most of our patients can apply them by themselves.
RK: It’s fantastic that it’s become so much easier to do at home, with some instruction initially. It makes it so nice for the person with diabetes and their caregiver to just be able to do this at home.
Can you talk a little bit about the receiver and the fact that some continuous glucose monitors allow you to see the numbers on your phone? This is pretty amazing; you don’t have to carry a separate receiver though some people might still prefer a receiver, which is just a separate device where they see the numbers. Can you talk about that difference?
AG: The receivers came to the market first. Some of the advantages of the receiver are that you don’t have to use your phone. Some people don’t want to drain their battery. Some people don’t want to sleep with their phone next to their bed. So they just have their monitor to alert them to the blood sugars without having their phone with them. It’s simpler; that’s all it does is just monitor the blood sugar; some people like that.
The advantage is when you use the phone as opposed to the receiver, you can connect to the clinic portals, and then we can monitor the blood sugars remotely. You can do that with the receiver as well, but the patient needs to physically plug it into the computer to upload it for us to see the data. When you use the phone, the data is updated all the time and can go straight to the portal without the patient having to do anything else once they’re connected to the clinic.
Using the phone also allows loved ones to follow the patient’s blood sugars as well. You can invite followers to see the blood sugar in real time, which is extremely helpful for a variety of cases. To have that ability to follow sometimes gives patients comfort, if they live alone, to have a child monitoring their blood sugar or a parent monitoring the child’s blood sugar or spouses, a spouse that travels; they want to make sure their blood sugars are okay. There are a lot of different varieties of cases where that can be very helpful when using the phone.
RK: I find that as long as the phone is compatible, some older phones may not be; patients appreciate having the same technological device that they use to talk to people to be able to also monitor their blood sugar. It’s amazing that those have become integrated.
Now, we’re talking a lot about the anatomy, and I hope we will get into the different kinds of CGMs, but I think it’s important to break down what people can expect if they’re thinking about placing a CGM and how much easier it has become to do this at home. Those are sometimes the types of obstacles that people might see to starting something new, but it’s reassuring to hear from you about how much more straightforward it has become how people can use the phone also as the receiver. What about downloading the data? You can see it on your phone. You can see it on the receiver, the numbers as you need them in real time. But when your healthcare provider wants to know what your numbers were like, with a glucose meter we used to have the old-school written logs of blood sugars, or they would be stored in the glucose meter where individuals could see their trends over time. How does it work for a continuous glucose monitor? How easy is it to extract the data from that so you can share it with your healthcare provider?
AG: It is straightforward. The receiver would be plugged in physically to a computer to upload to the portal. The phones, we just put a code in, and it automatically syncs with our portal. It gives us as providers so much information to look at and so many different factors to consider, as opposed to just glucometers again being just like pinpoints in time.
Here you’re getting the full picture of what’s going on with the patient. You can really pinpoint patterns much more easily with the sensor. It gives us different metrics to look at. In the past we just looked at A1C, and that’s all we had to assess a patient’s blood sugar control.
Now with the sensors, in addition to the A1C, we also look at something called time and range, which is really the time you spend between 70 and 180. For most patients with type 1 and type 2, we want that to be about 70% of the time. That’s important because you can have an average A1C of 7%, which is about a 154-blood sugar, but have wide fluctuating blood sugars—extremes.
With the sensors, you can see that you have an A1C of 7, but your time in range is above 70%. We know that most of those blood sugars are in a good range. These reports really show us a lot of information aside from just the pattern.
RK: I love the ambulatory glucose profiles that we get from the CGM as a healthcare provider: you can see patterns, you can see time in range, you can see the mean, the 50th percentile, you can see the percent of the time that you’re low, and when you’re low over the day too. It’s a standardized 24-hour profile of your average sugars in the ranges over time, usually during a two-week period, but sometimes longer. They are so helpful.
You talked about how they can easily be plugged in; the receiver can be plugged into a computer. Do patients usually do that on their own, or is that usually done at their healthcare provider’s office?
AG: It depends on the provider, but most clinics have the ability to download all the devices. If a patient needs to be monitored remotely—they had a virtual visit or something like that—that would be a time that they would want to upload their data remotely from home.
RK: I think that’s one of the things that has made it a little bit easier for us in diabetes care.[The ability] to do virtual visits or telemedicine visits, that capability. If the person with diabetes is able to download their numbers remotely, we can read them from anywhere. Then otherwise, coming into clinic and the clinic can easily download it. At every point from the insertion of the CGM to seeing the numbers on your phone or your receiver to downloading the data, I would say that more and more we have seen these processes become more efficient and smoother. Wouldn’t you say, overtime?
AG: Definitely. More patients are using them. A very large percentage of our population is using them because they’re so easy. They’re so accessible, a lot of insurances cover them well, and patients just find them so useful for their care. It takes a lot of the guesswork out of their diabetes.
RK: It doesn’t have to be a mystery. We have numbers now, and we can get lots of them. That has been really helpful. We’ve talked about the basic anatomy of a continuous glucose monitor. Now moving towards the categories of continuous glucose monitors. We know that these devices monitor blood glucose continuously, but the way that those numbers are displayed and available to the user may differ. I wonder if you could talk a little bit about real-time continuous glucose monitors versus intermittent continuous glucose monitors. Then if you want to touch a little bit about implantable continuous glucose monitors, that’d be great too.
AG: The intermittent, continuous glucose monitor, the one that’s on the market right now, is the Libre 2. Or the old Libre 14-day, which required the user to physically take their receiver or their phone and place it up against the sensor to scan it for the number. You can do that continuously; you could do it every few minutes, so you get a lot of data that way, but it won’t show you the number on the monitor unless you scan it. It will show you the patterns, though. If you scan at least every eight hours, it will fill in the data and show you what happened.
For instance, if you tested when you woke up in the morning and then scanned it and got your reading with the intermittent monitor and then scanned again at lunchtime, you would see what your blood sugar did from breakfast to lunch.
The disadvantage of that is if you only test twice a day, once in the morning and once at night, for instance, you might get gaps in your data, but some patients like that model because you don’t necessarily have it in your face all the time—you monitor it when you want to know what your blood sugar is.
The continuous glucose monitors send numbers every 1-5 minutes straight to the device, to the receiver, or the phone, or the pump, or the watch without having to do anything. You just look at it. So, a lot of patients find that more discreet. They don’t have to be in public and scan themselves, although it’s become so popular that it’s socially accepted to do that too. Some people just like having the discreet data. They could be in a meeting and just look at their watch and know what their blood sugar is—which is very valuable.
The implanted CGM, which is the Eversense, is very unique. It’s a little sensor that is surgically implanted under the skin. It just got approval for wearing it for a whole year, which is really exciting. On top of that, you wear the transmitter, which also sends the blood sugars to the phone. As opposed to the other sensors, if you take it off, you can’t put it back on that specific sensor. This one, you could take off the adhesive patch with the transmitter and then your sensor is still good, and you could just replace the transmitter when you need to.
RK: So that’s really helpful. You talked about the intermittent or flash CGMs, which currently sounds like we just have the Libre 2 or the 14-day Libre before. I like to think of those as the on-demand, CGMs. You get the numbers when you want them, but you really do have to wave that receiver over the transmitter to get the numbers.
Then you talked about the real-time CGMs, which are probably the most common type that we’ve had for a while. What are some examples of real-time CGMs that people might be familiar with on the marketplace?
AG: That would be the Dexcom G6, Dexcom G7, the Libre 3, and the Guardian sensor. Those are all sensors that send the data directly to the device without having to scan.
RK: The Guardian sensor, that’s the one that’s in Medtronic devices, is that right?
AG: That’s a Medtronic sensor. They have a specific sensor that can be worn as a standalone, and they also have a sensor that is worn just specifically with their pumps.
RK: So some of these CGMs, like we talked about, are standalone. You just use them on your own. Some of them, like the Guardian, can be part of a pump itself integrated into the pump and can transmit numbers to the pump to help with dose adjustments. Some are two different devices that communicate with each other. Isn’t that right? The pump and the continuous glucose monitor.
There are so many different variations. I think that the compatibility of these different technologies with each other is also remarkable, especially as we start thinking about an artificial pancreas or something like that in the future, and we could touch upon that later. But it is really remarkable all the different ways that these CGMs can communicate also with the insulin pump and other devices.
You lastly talked about the implantable sensor. Who usually places that sensor for the patient?
AG: There are some endocrinologists who do this in their office. Not all of them, not every office, but there are some providers that have been doing a lot of these. You’d reach out to the company to find a doctor in your area that is very comfortable with placing and removing these sensors.
RK: It is not something that a patient can do on their own—they have to go in. It is a minor procedure that they get done within a few minutes, I think.
AG: The sensor is really small. The Eversense also, the way it’s designed, to give on-body vibrations; if you’re low, the actual transmitter vibrates. Even if you didn’t have your phone with you, you still would know you were low because it would vibrate. That’s a different feature that some of the other sensors don’t have.
RK: That’s interesting—so you’d be shaken awake. Are there any new models on the horizon? Is there a Libre 4?
AG: No, there’s a Libre 3 Plus. I think where the future is going with these sensors is, like you touched upon before, more integration with more devices. The idea is we want to give patients a full range of choices. Eventually, you can pick your pump, you can pick your sensor, and hopefully they’ll all combine with each other. All the sensors are trying to get the most wear time to get that 2-week to 15-day wear time.
Recently there have been a couple of over-the-counter CGMs, which are new and unique. Dexcom now has one called Stelo, which is designed for people who have diabetes but are not on insulin and not on any medications that could cause low blood sugars. But they still, like we talked about before, really find it valuable to learn about their lifestyle and have that feedback. That’s an over-the-counter sensor that is not available at local pharmacies at this point. It is purchased online from their website. It is essentially a G7 sensor; it looks like a G7 sensor, but it doesn’t have the alerts in the app. The app is different; it gives a lot of lifestyle coaching, feedback, and education—it really guides patients and gives them feedback regarding their blood sugars. It is not intended for people who have the potential for low blood sugars.
Abbott also has one; it’s called the Lingo, which is essentially the form of a Libre 2. That’s actually not even for people with diabetes. That’s just for people that want to monitor their metabolic health and to get feedback that way. That’s also over the counter. It is not going to have alerts but just gives people blood sugar feedback.
RK: These over-the-counter continuous glucose monitors are really interesting. I think we’re learning more about them; they’re relatively new. I do think an important consideration that I share with patients or family members who are interested in using this or even friends is the accuracy, especially in people without diabetes, as we had talked about, particularly in the extremes of readings, if they are as accurate. The accuracy has been validated because they are on the market. But it’s always something to think about with any of these devices. If there is any discrepancy with what you’re expecting, consider the finger sticks or even a lab draw.
The availability is important because we know that not everyone who wants to use CGMs necessarily has access to them. I wonder if we could talk briefly about who CGMs are usually covered for; type 1 diabetes versus type 2 diabetes, and some of the challenges that you’ve seen in getting access or coverage for CGMs for patients that you have seen with diabetes.
AG: With anything related to insurance, obviously it varies widely regarding coverage and access. In general, patients with type 1 or anyone on insulin can access a sensor. Medicare requires at least one shot of insulin a day or a history of severe hypoglycemia, defined as needing assistance to treat. Sometimes the sensors are ordered through the local pharmacy, and some insurances require you to use medical equipment companies. So sometimes navigating that can be a little confusing for patients, which way it will be covered for them. For someone with type 1 or a patient with type 2 on insulin, it really should be covered (by insurance), and they should have access to it.
Some patients who may not be on insulin, who have type 2, some insurances will cover it. They just will cover it regardless of what medication they’re on. If there is a patient who, let’s say, doesn’t have coverage, that’s where something like the Stelo is helpful because they can purchase it at a more reasonable price and still have that benefit of seeing their data.
RK: Like you mentioned, anyone on insulin, with type 1 diabetes, whether they’re on an insulin pump or even insulin injections, or type 2 diabetes, one insulin injection or more a day coverage – while it differs by insurance company usually we can get coverage. Usually it is recommended to check your glucose readings multiple times a day if you’re on multiple injections a day of insulin, or at least once a day if you’re on basal insulin. So having the CGM can be helpful. I’ve seen, as you mentioned, people with type 2 diabetes who are on oral treatments; sometimes it can be more challenging if they don’t have private insurance to get coverage for a CGM because of what you mentioned with the Medicare specifications. For those patients, I do think that these over-the-counter CGMs could offer, hopefully, a cost alternative that might be more accessible. Wouldn’t you think?
AG: They’re still not cheap. They’re about $90 to $100 a month. For someone, though, who may be just wanting to monitor their patterns and food intake and things like that, it could be they may not need to wear it for a whole month straight, or it could be they can wear it for two weeks out of each month to just get a snapshot of what’s going on with their diabetes. They’re still not really cheap, but they are more accessible.
RK: Thank you for pointing that out. Do you know how much, non over the counter CGMs cost, with a prescription?
AG: I think it differs a little bit. Libre used to have a coupon that would get it to $75 a month with a prescription. But some insurances are starting to not, or the coupon may not work so well with everyone now. Then it could be, for Dexcom, about $170 per month for it. There is a bit of a cost saving.
RK: Needless to say, these devices are not cheap. Having coverage is incredibly important for those who could benefit from it, and having it be accessible to people with diabetes, not only in the United States but around the world, that really could benefit from them, is also important.
I think as we think about technology and diabetes, it’s an exciting time, but it does need to be an exciting time for everyone who can benefit from them.
We talked about the different categories of CGMs and you talked about a few models within each of those categories. I wonder if you could just broadly talk about some different features that continuous glucose monitors can offer.
We talked about the trend arrows telling you if you’re going high or low. You talked about the functionality of being able to predict almost in 15-20 minutes if you’re going to go low or not. Are there other features that might be interesting for our listeners to hear about?
AG: he share feature, I think I mentioned before, is one of my favorite features. It’s not for everybody, but it is a nice feature for a lot of people to have that ability to share their data. Other features—what devices they’re integrated with…
RK: How about calibration? Do all of these continuous glucose monitors require finger sticks to confirm values that might be too high or too low, or do they replace the need for finger sticks altogether?
AG: We talked a little bit about when you might want to take out your meter to test. With some of the monitors, you can’t calibrate. The Libre is a sensor that you can’t calibrate. The Dexcom, while we don’t recommend it often, you do have the ability to calibrate if you want to, but you don’t need to. The Guardian and the Eversense, you do need to calibrate. They do differ in that way.
RK: What does that mean? What does calibration mean?
AG: Calibration means [that] at the same time you prick your finger with your glucometer and input that number into the monitor, and then it matches up the sensor and the blood sugar number together.
RK: In terms of using the numbers from a sensor for treatment decisions, from what I understand and what I’ve seen with my patients, some of the sensors, you don’t need to do anything more than that. They replace the need for finger sticks, as long as they’re not too low or not too high. Could you talk a little bit more about that and what devices those might be?
AG: All of the available sensors right now are approved to dose that your insulin off of. As long as you have a number and an arrow on the monitor, you can dose off of it. Sometimes if there’s no arrow or if the monitor is telling you to prick your finger, that may be a time where you wouldn’t trust the sensor necessarily—you would take out your glucometer. In general, most patients don’t need to do that, and they’re testing their blood infrequently and relying mostly on the sensor.
RK: I have patients who’ve been finger-pricking four times a day for decades and then finally now are at a place where they have a sensor, where they almost never need to do that anymore. It’s pretty remarkable. These have been game changers, haven’t they?
AG: Yes, definitely.
RK: So we covered a lot of ground today, and we really appreciate you, Adena, breaking down the types of CGMs, their functionalities, who usually can benefit from them, and the over-the-counter options as well. In this rapidly changing time, it just seems like there are so many new updates to the technologies. How do you recommend your patients keep up with them? To know the newer models, I’m sure there are software updates that need to be done at times too. How can they keep up with the changing technology to make sure that they’re getting the most up-to-date versions that are out there?
AG: In terms of technology in general, I think when you come in for your office visit with your doctor, I think that’s a great time to revisit what’s happened, because the technology does change every 3, 6, or 12 months. I think, from a bigger picture, checking in with your doctor’s office is important, and there are lots of other resources online. The Johns Hopkins Patient Guide to Diabetes has a very good reference for technology and updates and comparison charts between the different devices because they’re all so nuanced.
We talked generally today, but they’re all very specific and a little bit different from each other. In terms of making sure your device is up to date, if you register your device, which you typically do when you get it, you should get a notification if you do need to update something. Generally, when there’s phone integration with the sensors, we tell patients to turn their automatic updates off on their phones because sometimes the latest version of the operating system may not be tested yet with the sensor. So, leave that off, and then when you get the go-ahead and you find out that it’s okay to use, you can go ahead and update your phone with that latest operating system.
RK: That’s important to emphasize registering your device so you can get those communications. Thanks for pointing out the resources out there to continue to learn more about new technologies and new devices that might be coming out on the horizon.
Adena, it’s been so great to talk to you today and to hear in a practical way the things that people with diabetes should be aware of as they consider these technologies, the exciting developments we’ve seen with continuous glucose monitors, who might be suitable for them and for whom, perhaps the glucose meter or less frequent glucose checks might be more appropriate, and then also, what are some of the functionalities that have really facilitated the day-to-day management for people with diabetes.
In parting, I wonder if you might have a few words for people out there that are listening who might still be a little reluctant to try these new technologies out. Maybe they’re used to their day-to-day management. Maybe they don’t want to complicate things anymore. What would you say to them about considering these technologies and integrating them into their day-to-day management?
AG: I have so many patients who tell me that the CGM has been the one most life-changing thing for them in the course of their diabetes management. It is a lot of information, and you do have to get used to that. For most people, there’s really a comfort to it, and it really takes a lot of the mental burden and worry out of their diabetes. You’re not worrying [about] what your blood sugar is because you know what it is. If you’re not feeling well, you can confirm, “Am I just not feeling well, or is my blood sugar abnormal?” It really gives people a big comfort. It’s much smaller, much more comfortable to wear—most people forget they’re even wearing it.
I would really encourage people to just talk to your provider about trying it. It’s not a big commitment. You could try it for a few days, a week, or two weeks; see if you like it; see if it helps you. For the majority of our patients, it is really life-changing and such a helpful tool to help them thrive with their diabetes.
RK: Definitely, talking to the healthcare provider, seeing if this might be for you, and seeing what the options are, especially if these numbers can give some reassurance and also some insights into behavioral patterns that can ultimately lead to improved outcomes. That’s ultimately what we want for everyone.
Adena, thank you so much for being here on our podcast. We really appreciated all your expert insights and your input today.
AG: Thank you for having me.
RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit hopkinsdiabetesinfo.org.
We love to hear from our listeners. The email address is hopkinsdiabetesinfo@jhmi.edu.
Thanks for listening. Be well and see you next time.
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- Home - | - Episode 44: Adult Onset Type 1 Diabetes, A Real Patient StoryIn Episode 44, Dr. Kalyani welcomes Beth, a person who has adult onset type one diabetes who will be sharing her journey with this condition. Along with Beth, we are pleased to welcome Dr. Jordan Perlman. Dr. Perlman is an assistant professor of endocrinology at the Johns Hopkins University School of Medicine. Her clinical practice focuses on using diabetes technologies in older adult populations. She is involved in clinical trials testing new algorithms for automated insulin delivery systems. She has been recognized for her work on continuous glucose monitoring metrics. and the associated risk of microvascular complications. Dr. Perlman was named a top doctor in endocrinology by Baltimore Magazine in 2023 and 2024.
Download Transcript← Previous PodcastNext Podcast →Podcast 44: Adult-Onset Type 1 Diabetes, A Real Patient StoryDr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani, at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.
For today’s podcast, it is my pleasure to introduce Beth, a person who has adult-onset type 1 diabetes who will be sharing her journey with this condition. Along with Beth, we are pleased to welcome Dr. Jordan Perlman.
Dr. Perlman is an assistant professor of endocrinology at the Johns Hopkins University School of Medicine. Her clinical practice focuses on using diabetes technologies in geriatric and disabled populations. She is involved in clinical trials, testing new algorithms for automated insulin delivery systems. She has been recognized for her work on continuous glucose monitoring metrics. and the associated risk of microvascular complications. Dr. Perlman was also named a top doctor in endocrinology by Baltimore Magazine in 2023 and 2024.
We are thrilled to welcome Dr. Perlman and Beth here today. Welcome.
Beth: Thank you.
Dr. Jordan Perlman, MD: Thanks, Dr. Kalyani. So, Beth, I know everybody is really excited to hear your story. Can you tell us a little bit about the circumstances of your diagnosis? When were you first told that you had diabetes?
Beth: Sure! Thank you again for covering this topic, because type 1 diabetes is rare, and my adult onset is the rarest of the rare, correct me if I’m wrong. It is a tough group to be in for sure. I was originally diagnosed with type 2 diabetes. It was really gestational diabetes when I became pregnant with my son, who’s now 22 years old.
I was seeing a family physician; I was young, and a friend of mine suggested that I see her doctor, who had delivered her child. So, I didn’t even go to an OBGYN. The doctor was very wonderful; he was a brand-new physician out of medical school. And what happened was my glucose test, during my pregnancy; the results apparently never made it back into my file. So, I went undiagnosed with gestational diabetes. We don’t really know how long I was undiagnosed for, but I became extremely ill, of course, in my second trimester. My physician at the time was worried I was getting dehydrated and told me to drink Gatorade (a sports drink containing electrolytes and glucose), which, of course, was just exasperating all my symptoms. Eventually I called my doctor, and he said, “You have to come to the emergency room.” They tested my glucose, which was somewhere in the five hundreds. They admitted me right away. And my physician told me that those glucose test results had not made it back into my file — he didn’t catch it. I was referred to an OBGYN who specialized in high-risk pregnancies. So, from that point on, I became a high-risk pregnancy. It was very difficult to control my gestational diabetes; I was on bed rest, and it was just difficult. After my son was born, it was a miracle, and I no longer had diabetes. They brought me a piece of cake in the hospital, and I was like, “Get that away from me!” and they were like, “We just want you to try this.” My glucose remained completely beautiful — perfect — there was no increase. That was a really wonderful moment for me.
Fast forward five years. My husband and I really wanted to try for another child, but my doctors told me that I was at higher risk, not just for gestational diabetes, but for becoming type 2 permanently. I really did everything I could to make sure I was in prime health to get pregnant. I got pregnant. We were living here in Baltimore at the time, and I started seeing a high-risk obstetrician and just a wonderful OBGYN. He managed my gestational diabetes — I did in fact develop it. It was very well controlled throughout my pregnancy. However, upon the birth of my daughter, who is now 17, I was diagnosed as a type 2 diabetic.
So, for many years, I was treated as a type 2, but I was really a brittle type 2 (diabetic). I had a lot of difficulty controlling my glucose; I was on metformin, of course, and the insulin-resistance drugs that you take. We were experimenting with different drugs. Then eventually test results showed—this was about five years ago, so I was about 45 years old or 46—test results showed that I was no longer a type 2 (diabetic). I was a type 1 diabetic, and that was pretty devastating.
JP: Wow. That is very complicated. It’s a really interesting story, and it sounds like you had to go through a lot before you got your diagnosis of type 1 diabetes with adult onset. I’m just curious, for those who are listening, if you could tell us a little more. You said that during your first pregnancy, your doctor said that you were getting dehydrated. How did your doctor know? Or how did you know that you were in trouble during your first pregnancy? What kind of symptoms were you having?
Beth: Sure. I had every possible complication you could have during pregnancy, with the exception that I never developed preeclampsia, but that was the only thing I didn’t develop. My symptoms were thirst and incredible fatigue. I remember trying to get up the stairs to my apartment, and I was just on the second floor—I felt like I was wading through six feet of snow, like my body just had no energy. I couldn’t satisfy my thirst; I was sleeping all the time; I felt like I had brain fog, and because I was pregnant, people were like, “Oh, you’re tired because you’re in your second trimester.”
My family was noticing my symptoms. I had a lot of edema in my feet and my legs. In fact, I think I had a baby shower, and two days later, I was in the hospital for extreme swelling. They were just trying to get it all under control. I developed—now this is not necessarily a symptom of diabetes, but maybe a complication—I developed severe cellulitis in my leg, which was extremely painful. They had to do an X-ray; they were worried about blood clots. I had to sign away my life to have the X-ray as a pregnant woman. I would say to family, “I’m the only one who goes into the hospital, into labor and delivery, and leaves still pregnant.” I was just hospitalized many times. Those were the early symptoms. By the time I was getting hospitalized, they knew that I was an uncontrolled gestational diabetic, but it was very rough going.
JP: You mentioned that your diabetes was then well controlled during your second pregnancy. What changed during your second pregnancy? What were you doing to control blood sugars during your second pregnancy?
Beth: The difference was excellent health care. I was now in Baltimore; I just had access to excellent health care from the very beginning. We went into the pregnancy knowing that I was going to develop gestational diabetes, most likely, and that because of my medical history, it had to be very tightly controlled. I had weekly doctor’s visits. I think by my second trimester, I was going in twice a week to see my OBGYN. And I was on insulin, so we were controlling my glucose with insulin and with a very strict low-carb diet.
JP: So, you were taking (insulin) shots during your pregnancy?
Beth: Yes.
JP: After you delivered your daughter, you were told that the diabetes had now become type 2 diabetes; were you still taking insulin after you delivered your daughter?
Beth: For a while, it was controlled with Metformin and with Liraglutide (Victoza), and honestly, I was on a few different pens for a while; I can’t even remember all of them. I had really significant insulin resistance and still do, and that’s a scary place to be.
JP: Are you talking about with regards to how much insulin you’re requiring now as an adult or how much you were requiring during pregnancy?
Beth: So during pregnancy, because I was type 2, I was on insulin, but I wasn’t on a whole lot—maybe 5 units to treat any number of carbs. I’m not being medically accurate here because I just can’t remember what my ratios were, but I was not taking a ton of insulin. Maybe my total daily dose at that time—an expression I didn’t even know to use incidentally but use now—with my second pregnancy was probably around 35 or 45 units of insulin. As I increasingly became harder and harder to control, as my daughter grew, and years went on, my A1C numbers were like 7%, 8%, or 9%, really not where you want to be. By the time my A1C was 9%, that’s really when we realized that I had become a full-blown type 1 diabetic.
JP: Yeah, so let’s talk about that transition. You may know this already, but for those of you listening, one of the ways that doctors often consider a misdiagnosis when it comes to type 2 diabetes versus adult-onset type 1 diabetes is how quickly a patient progresses from needing your typical type 2 diabetes medications like Beth described—so your oral medications and your non-insulin injectable medications like liraglutide (Victoza), semaglutide (Ozempic), and tirzepatide (Mounjaro) —and how long it takes a patient to fail those medicines and need to start taking insulin. I think you said that it took you five years to go from a diagnosis of type 2 diabetes to getting your diagnosis of Latent Autoimmune Diabetes in Adults (LADA). That is a pretty quick progression for a young person diagnosed with type 2 diabetes to go from non-insulin medications to insulin medications.
I do think that is a pretty classic red flag for a doctor to consider whether or not you might have an autoimmune process like type 1 diabetes versus type 2 diabetes. I think that that in and of itself is pretty telling. When you delivered your daughter and then you were told you had type 2 diabetes, what was your understanding of how common it was for patients with gestational diabetes to then develop type 2 diabetes?
Beth: I think my husband and I were really hopeful that if I developed gestational diabetes with the second pregnancy, I would be lucky and deliver, and I would have that magical moment I did with my son, and I would no longer be diabetic at all. I think in my third trimester, my doctor was on vacation, and I had an appointment with another OBGYN, who delivered information in a very different way to me and said, “You’re going to deliver, and you’re going to be a type 2 diabetic.” I was just like, “What!? What do you mean? Is it that certain? I’m 100% becoming a type 2 for life!?” It was really shocking. I really didn’t know just how likely it was, and I wasn’t getting bad information. I just really, for whatever reason, didn’t understand that—yes, I am most likely going to become a type 2 with my second child. Now, looking at my family and family medical history, I had a cousin who had gestational diabetes with both of her pregnancies, and she’s not a diabetic; she did not become a type 2. Type 2 diabetes is rampant in my family: my father has been a long-time type 2; I have three siblings; my sister has type 2, and my brothers are okay. My mom developed it later in life. Then just any number of aunts and uncles developed type 2 later in life. But to our knowledge, there hasn’t been any type 1 diabetes in our whole extended family.
JP: That’s very interesting. But believe it or not, it is not uncommon. Type 1 diabetes doesn’t necessarily run in families, but type 2 diabetes is very highly genetically correlated. When you were failing all of those medications for type 2 diabetes and your A1C was going up and up and up, do you remember what tests were done to determine if you had type 1 diabetes versus just difficult-to-control type 2 diabetes?
Beth: While I was type 2, I was having all the standard tests, and if you could maybe remind me of what some of them are.
JP: Yeah, if a doctor suspects that a patient may have type 1 diabetes instead of type 2 diabetes, there’s a series of tests for autoantibodies—so antibodies in the body that mistakenly target your pancreas—as well as an assessment of how much insulin your pancreas is producing. So adult-onset type 1 diabetes, classic type 1 diabetes, they typically present with at least two of these autoantibodies, these antibodies against the pancreas. And if it’s found early, sometimes patients will have some residual insulin function from their own pancreas. But oftentimes, by the time we find out that someone has type 1 diabetes, they may not have any remaining insulin function. That’s when it gets really dangerous because those patients are at high risk for a complication called diabetic ketoacidosis. That was a buzzword for a lot of people because it can mean death. It’s a really serious complication. I’m thinking that it’s likely that your type 1 diabetes was diagnosed on a series of blood tests after you continued to have a rising hemoglobin A1c using these oral and non-insulin type 2 diabetes medications.
Beth: Correct, so they did the antibody test, and I was no longer producing any antibodies, and my pancreas was no longer producing any insulin. And I cannot emphasize enough the importance of good physicians. When I was pregnant with my son, I was in Buffalo, New York, and I was young. I wasn’t really plugged into communities with young parents and people who could refer me to good health care and good physicians. All that changed when I came to the wonderful state of Maryland and Baltimore with Hopkins and GBMC.
This sounds ridiculous, but with the advent of Facebook, I eventually joined. Once it was just becoming very difficult to control diabetes, and then when I was diagnosed with type 1 diabetes. That was here in Baltimore, incidentally. But I literally got a call from a nurse, not even my endocrinologist, who called to say you’re now a type 1 diabetic. I didn’t know what that meant. I kind of knew, but she said, “You can stop all of your type 2 medications. You can stop Liraglutide (Victoza), you can stop your metformin, and we’re just going to treat you with insulin.” Then my endocrinologist, who’d been treating me for years, left the practice. So, I had no guidance. I stopped taking my type 2 (diabetes) medications. And what I’m going to tell you is that my glucose went through the roof: my glucose was at 300 mg/dL; it was at 400 mg/dL, and I couldn’t get it under control.
I didn’t know what to do, and I joined this Facebook group for type 1 diabetes. A few people reached out to me because they could tell I didn’t know anything; I didn’t know what a bolus was. I have a PhD in English, incidentally, and I know how to research things. I couldn’t figure out what I was supposed to do. Via Facebook, somebody referred me to Hopkins, and I had to wait six months as a new patient to get into him, but they said, “It’s worth it.” So for six months, I really did not have a whole lot of guidance for treating what was now my type 1 diabetes, but a friend who I’d made through the Facebook group—and I don’t recommend ever taking medical advice from anyone who’s not a physician—but she had been a type 1 her whole life. She’d been a juvenile diabetic, and she said, “Beth, take your metformin again.” And I started taking my metformin, and I was able to reduce my glucose. Not as much as I would like, but at least it was making a difference while I was waiting to get in to see my new endocrinologist.
RK: So Beth, thank you so much for sharing the challenges of trying to figure this all out. It’s so interesting to hear about the role of social media in providing some information and support. I wonder, as we talk about how difficult it can be, especially in adults, to diagnose the type of diabetes, if we could talk a little bit about what we thought was going on during your pregnancy. Often, one type doesn’t change into another. We think more often that you probably had type 1 diabetes, and it was likely misdiagnosed because gestational diabetes is very common in women when they’re pregnant. Perhaps it wasn’t until you got to the point where your body wasn’t producing insulin that they started to think about the type.
I wonder, Dr. Perlman, if you could shed some light on the misdiagnosis versus having one type versus another, because we don’t usually think about one type becoming another type, but the messaging is important. Beth, I think what you’re sharing is some of the confusion about that.
Beth: Definitely.
RK: And trying to navigate that. Dr. Perlman, I wonder if you could provide us some insights into that.
JP: Absolutely. I think the big takeaway here is that hindsight is 20/20. I think it was a totally reasonable assumption, particularly because you’d had gestational diabetes twice, and you said that you have a pervasive family history of type 2 diabetes. I do think that it was a reasonable assumption, after you delivered your daughter, that you had type 2 diabetes. But there are certain things that we will sometimes look for to indicate whether someone has type 1 or type 2 diabetes.
Oftentimes, type 2 diabetes comes with a lot of other metabolic problems, hypertension, high blood pressure, high blood lipids or high cholesterol, and obesity. Even though it is quite common for us to see type 2 diabetes after gestational diabetes, there are certain things that would make us question that diagnosis.
I think that your story of, as Dr. Kalyani described it, having to wait a long time and to wait until your pancreas stopped making insulin to get a diagnosis of adult-onset type 1 really is, unfortunately, a classic story. But yes, it is likely that you had the beginnings of type 1 diabetes and not type 2 diabetes after you delivered your daughter. And because the disease classically progresses slower in adults, it was able to hide out and pretend to be type 2 diabetes until you had no remaining insulin function and your body was dependent on insulin injections to survive. So, I do think that the course is quite classic, but I think it’s important for our listeners to understand that it was likely—it is likely—that you had type 1 diabetes after you delivered your daughter, and that it really just progressed slowly.
Beth: I do think you are absolutely correct about that. Even in just the past few years, I’m seeing more and more research on what you referenced as LADA, or latent autoimmune diabetes in adults. When I was diagnosed with type 1 (diabetes) several years ago, that was not in the conversation. I found that on a website, and I wasn’t even sure if that was in mainstream medical research yet, just as a patient looking for answers. So, I do think that you are right. I think I had a lot going on metabolically; I am treated for hypothyroid, and now I’m treated preventatively for high blood pressure, just to keep everything at bay.
JP: Can you tell us a little bit more about how you’re currently managing your adult-onset type 1 diabetes?
Beth: Thank you for asking the question because I really want to share this with people who might be in my situation. How do you control this really tricky type 1 that comes on in adulthood? I was already on a continuous glucose monitor (CGM). It was wonderful being able to see my glucose levels. I’m a huge fan of CGMs, and I’ve only ever used Dexcom, but that was my first game changer.
Then the second game changer for me was the pump (an insulin pump). I’ve been on the pump since 2020; it was the highlight of the pandemic for me. I was able to get the pump, and my insurance covered it.
Three game changers: my endocrinologist, the CGM, and the pump. My A1C was maybe still around 7.5% or 7%, still hard to get any lower than that. What I was really struggling with was weight gain from all the insulin. Because of my insulin resistance, which is so much higher than somebody who’s a juvenile diabetic and has been managing their diabetes pretty well throughout their life, I was taking—this just still astounds me—upwards of 100 units of insulin a day to control my diabetes.
I maybe wasn’t doing the best job with my diet. But I wasn’t sitting around eating entire pizzas or candy bars and ice cream, and I was still taking a hundred units of insulin. I put on 30 to 40 pounds. I had never been heavy in my life. Now I was tipping the scales; I couldn’t fit into any of my clothes; I was at the weight that I was at when I was pregnant. I was really depressed because I could not get the weight off. I go to the gym, and I get on a bike, and my glucose would instantly crash, and I’d be drinking juice, which was no help in trying to control my weight. It was really tough. Everybody is talking about semaglutide (Ozempic) and tirzepatide (Mounjaro), and it’s not FDA approved for type 1 (diabetes). Then there’s me, and there are the other type 1s who are adult onset and have insulin resistance, and mine is pretty significant. Then the insurance rejected it.
My sister, who has type 2 diabetes, is on semaglutide (Ozempic); she was just having great results. I was sitting on the sidelines thinking it’s just so unfair that my insurance won’t cover it. But we kept trying. I learned from my Facebook group that if your doctor checks the right box for your insurance that says insulin resistant, many insurances will cover it. As your listeners may know, semaglutide (Ozempic) and tirzepatide (Mounjaro), that whole class of drugs, is so expensive out of pocket; it’s $1200–$1500 a month. I just couldn’t do it; there was no way. So tirzepatide (Mounjaro) gets approved by my insurance, and that was the fourth major game changer for me. I have more energy—I’m not at a hundred percent as a diabetic—but I have more energy. I have also lost about 30 pounds. I’m fitting into clothes that I haven’t fit into for seven years. All of my numbers, all of my tests for cholesterol and high blood pressure—I am at the best health I have been at since my thirties. There was definitely a transition at first with the nausea and whatever. But thankfully I’ve adjusted to it.
JP: I know we could do an entire podcast series on insurance and coverage. I certainly want to touch on something important that you said, which is the issue of insulin resistance. I think it’s an outdated idea that only people with type 2 diabetes can have insulin resistance. Insulin resistance is something that can also affect people with type 1 diabetes.
There are many causes of insulin resistance; the one that you mentioned was weight. Unfortunately, with insulin resistance, gaining weight is a feedforward mechanism because you gain weight, you develop insulin resistance, and then that extra weight causes you to develop more insulin resistance. Then it’s a self-fulfilling prophecy. It’s true that patients with type 1, adult-onset type 1, and type 2 diabetes can all have insulin resistance. I think that moving forward, it’s going to be interesting to see what the studies show us about the use of these GLP medications and type 1 diabetes.
Going back to your use of the insulin pump, the automated insulin delivery system. Can you tell us more about how you adjusted to that as an adult? One of the things that I often think when I treat patients with adult-onset type 1 is how much easier this must be—and I’m not saying that being a child with type 1 diabetes is easy; it’s certainly not—but if you’ve lived your whole life, not having to wear devices or worry about taking insulin with your meals, I think it must be a lot harder to adjust to this kind of technology. So I’m wondering if you could tell us about your experience using this automated insulin delivery technology. Do you have any advice for other adults who may be struggling with the technology piece of this?
Beth: I love technology; I always have. I think even for those who may be averse to the idea of having tubing and a little electronic device on their person at all times, you get used to it. Like you said, Dr. Perlman, it’s so much easier. It takes the math out of it if you don’t like math, or you don’t like having to figure out your ratios of carbs to insulin. I don’t wake up in the middle of the night with my CGM going off. I think they call it the “sunrise effect,” if I’m not mistaken. But my glucose goes up in the early hours of the morning before I wake, so my t:slim pump will cover for me. It’s amazing. I have to bolus before a meal, but I just punch in how many carbs I’m going to be eating.
If you’re a type 1 diabetic, you just get really used to doing that. Before the pump, I was using apps to help me track my carb intake and my insulin usage. That was early data that I was able to give my endocrinologist before I was on a pump. It’s a lot. It’s like walking around and having to have Excel spreadsheets so you can figure out how your body is handling carbs. I pretty much just wear clothing with pockets now because I just slide my pump into a pocket, and I cut a little hole in a pocket, and that’s where my tubing goes.
You figure these things out, or if you’re in a Facebook group or you have a community—Hopkins has a group for diabetics to meet. You learn these little tricks of the trade that can make life easier. I can look at my total daily dose, and it’s just knowledge is power, and the pump gives you control over that information to give you control over your diabetes.
RK: Beth, it’s so great to hear how technology has really supported the management of diabetes for you. As Dr. Perlman mentioned, sometimes when you’re diagnosed with a chronic disease later in life, it can take some more adjustment. It sounds like you’ve adjusted and thrived so well with your current treatments. Part of the challenge that I think you’ve highlighted that I thought was worth commenting on was what we call the “overlapping physiologies of diabetes”—even though you have the diagnosis now that they found the type 1 diabetes, given your family history and the weight gain, you also probably do have some insulin resistance. We see that even with children who are diagnosed with type 1 diabetes as they get older, if they have other risk factors for insulin resistance or type 2 diabetes, we can see that high insulin need. I really do appreciate you sharing your story and especially the challenges of having not only a confusing diagnosis but maybe having aspects of both type 1 diabetes and insulin resistance.
Now that you’ve had these years of meeting with healthcare professionals, being told at various stages of testing what they think you have and what you have, and with the support of the Facebook group—how do you feel now that you have the diagnosis?
Beth: I feel so much better than I did five years ago when I was really scared. I feel like I’m tuned into my body in ways that a healthy adult or even an unhealthy adult is not tuned in to their bodies. I like that because, again, my doctors and my PCP are on top of making sure I’m managing my diabetes and any kind of complication that can arise from it. I think my children are very aware, and my husband is very tuned into my health. My husband’s phone is linked to the app because I tend to work from home, by myself, or I’m in my office by myself. If I’m having a low, my husband gets alerted, and he checks in with me to make sure I’m okay and that I have access to some quick carbs. I feel empowered to really control my disease and aim for being the healthiest that I can be so I can live a long, healthy life for my family.
JP: That’s really great. Is there anything specifically that you would want other doctors and healthcare providers to know, in terms of how we can better support individuals with adult-onset type 1 diabetes?
Beth: I think you all doing this podcast is just fantastic. I would just say, I don’t think a lot of medical professionals or endocrinologists necessarily know the great resources that are out there for type 1 diabetics. There are some great websites. These are things that were shared with me through the type 1 diabetic community. I think just making sure that patients have resources outside of the doctor visits. I see my endocrinologist twice a year; I see his nurse practitioner twice a year. That’s just two to four touchpoints a year. Diabetes is tricky, but there are podcasts like this one.
JP: In our clinic, we definitely take advantage of some of the newer technology options, particularly when it comes to helping patients learn to count carbohydrates. ChatGPT is a great resource.
Beth: Oh, wow. I hadn’t even thought of that.
JP: Yeah, artificial intelligence (AI), I think, is really helping patients with diabetes learn to do things like carb count. As Dr. Kalyani mentioned earlier, I think it’s great that you’ve been able to connect with other patients, to learn about their stories, and see if they have any “tricks of the trade” that will work for you.
RK: Thank you, Beth, for being on our podcast and for sharing your story, which I’m sure will resonate quite a bit with other listeners out there, and for sharing the resources also that you have found helpful to navigate this.
One thing I did want to ask Dr. Perlman is if you might want to touch briefly on the terminology that we now use for adult-onset type 1 diabetes versus latent autoimmune diabetes of adulthood, which is sometimes used as well.
JP: The terminology, I think, for the layperson can be tricky. I think the bottom line is just to understand that both latent autoimmune diabetes in adults versus adult-onset type 1 versus type 1 diabetes all have a very similar pathophysiology. They have a similar cause. It all has to do with autoimmune destruction of pancreatic beta cell function—so the cells in the pancreas that make insulin get destroyed. I think the more recent terminology is adult-onset type 1 diabetes. If you hear someone referring to it as latent autoimmune diabetes in adults, or LADA, they’re referencing adult-onset type 1 diabetes.
RK: It can be confusing even for us in the health care field. We can only imagine how confusing it is for a person with diabetes. The bottom line is to learn as much as you can, to understand as much as you can, and to get the treatment as promptly as you can.
Beth, your story has been so great to hear, not only about the challenges and how you were able to find support to navigate those but also to hear what a great place you’re in right now and how well you’ve been doing.
I wonder, in parting, if you might have some words for anyone out there who is struggling with their diabetes and wondering, like you did, is this the right diagnosis? Who else can I ask? What would you say to them?
Beth: I would say number one, find a great endocrinologist; research who the best endocrinologists are, and know that you can leave an endocrinologist if you’re not getting the answers that you need or want or think that you need. Number two, never give up. Never give up. This disease has its ups and downs, and I’ve certainly experienced the whole gamut, and it can get you down, but just never, ever give up on yourself or your disease. You can get control of it.
JP: That’s wonderful to hear. We definitely love the positive encouragement. I agree with you; if you, for some reason, feel in your gut that something isn’t right, you absolutely should seek out somebody who can help you find the answers. In endocrinology, that’s a big part of our job: looking for answers and making diagnoses. It was really great to hear your story, and I’m really impressed with how well you’ve integrated technology into your life as an adult and that you haven’t been hesitant. You’ve just gone for it, and I think that is really impressive.
Beth: Thank you so much. Thank you all for the wonderful work that you’re doing supporting diabetics and diabetes education. It’s just so important to have these resources and experts in the field.
RK: Well, thanks so much again for being on our podcast. We really appreciated your time and your willingness to share your story. Thanks again. Thanks, Dr. Perlman, for your expertise and shedding light onto adult-onset type 1 diabetes, which I think we are going to hear more and more about. We really did appreciate having you both on our podcast today, so thank you.
Beth: Thank you.
JP: Thanks.
RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit hopkinsdiabetesinfo.org.
We love to hear from our listeners. The email address is hopkinsdiabetesinfo@jhmi.edu.
Thanks for listening. Be well and see you next time.
- Home - | - Episode 43: Diabetes & Bone HealthIn Episode 43, Dr. Kalyani welcomes Dr. Kendall Moseley. Dr. Moseley is the Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism, Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center, and Co Director of the Johns Hopkins Multidisciplinary Parathyroid Clinic. Dr. Moseley received her medical degree from Baylor College of Medicine in Houston, Texas, followed by internal medicine residency training at the Johns Hopkins Hospital. Upon completion of her endocrinology fellowship at Johns Hopkins, she joined the faculty in the Division of Endocrinology, Diabetes, and Metabolism of the Johns Hopkins University School of Medicine. Dr. Mosley has a dynamic clinical practice and collaborations within the institution that focus on metabolic bone diseases, osteoporosis, hyperparathyroidism, vitamin D deficiency, atypical fractures, and skeletal survivorship. She is actively engaged in NIH funded clinical and translational research involving the relationship between type two diabetes, osteoporosis, and aging. She’s additionally involved in research investigating mechanisms by which chronic disease states, such as malignancy, HIV, hepatitis C, and cystic fibrosis impact bone quantity and quality.
Download Transcript← Previous PodcastNext Podcast →Podcast 43: Diabetes and Bone Health Dr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani, at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org. Today, we are thrilled to welcome Dr. Kendall Moseley. Dr. Moseley is the Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism; Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center; and Co-Director of the Johns Hopkins Multidisciplinary Parathyroid Clinic.
Dr. Moseley received her medical degree from Baylor College of Medicine in Houston, Texas, followed by internal medicine residency training at the Johns Hopkins Hospital. Upon completion of her endocrinology fellowship at Johns Hopkins, she joined the faculty in the Division of Endocrinology, Diabetes, and Metabolism of the Johns Hopkins University School of Medicine.
Dr. Moseley has a dynamic clinical practice and collaborations within the institution that focus on metabolic bone diseases, osteoporosis, hyperparathyroidism, vitamin D deficiency, atypical fractures, and skeletal survivorship. She is actively engaged in NIH-funded clinical and translational research involving the relationship between type 2 diabetes, osteoporosis, and aging.
She’s additionally involved in research investigating mechanisms by which chronic disease states, such as malignancy, HIV, hepatitis C, and cystic fibrosis impact bone quantity and quality. Welcome Dr. Moseley.
Dr. Kendall Moseley, MD: Thank you so much, Dr. Kalyani, for having me today. I very much appreciate the ability to talk about type 2 diabetes.
RK: We are so thrilled to have you here and to talk about the condition that we don’t give as much recognition to as we should in clinical practice, which is the relationship of type 2 diabetes to bone health. I wonder if you could start off by telling us—how does type 2 diabetes impact the bone?
KM: I think that that is an excellent question. It’s funny when we think about bone disease and, particularly, osteoporosis or fracture risk—I think a lot of us have in our minds a picture of the typical person who’s going to break a bone. These are individuals, men and women; we probably think about women more than we think about men, but believe it or not, both sexes can get osteoporosis. Women typically are on the smaller side. We might even describe them as being frail. They are thinner, they have lower muscle mass, and they may look a bit unsteady on their feet. Certainly, walking down the street, you see someone like that, maybe hunched over a little bit, and you would worry about their bone health and worry about their fracture risks.
As time has passed and we have looked at some of these large clinical trials, and we have really worked through some of the data, we realized that individuals who look absolutely nothing like that woman or that man that I just described are at risk. Individuals with type 2 diabetes needing oral therapies or insulin therapies are also at risk for fracture, and they aren’t necessarily thin; they’re not necessarily frail appearing. When we look at the data, there is this increased risk of fragility fractures. So, these are not something you would have after getting into a car accident or falling out of a two-story building. Rather, we are talking about fragility fractures—falling from standing height or less, slipping on ice and breaking your wrist, or falling backwards and breaking a bone in your back; sometimes even silent fractures. We are seeing these more in individuals with type 2 diabetes, which has really given us pause to think about the mechanisms when we otherwise were not expecting it. It was a hidden complication of type 2 diabetes that is just now making it into commonplace knowledge.
RK: It does sound like, though it may be a hidden complication, a complication that can have tremendous consequences on mobility and movement. Fragility fractures, as you mentioned, we usually think of in older people, but can younger people with type 2 diabetes get this as well? Is this something that can occur across the lifespan?
KM: Absolutely. The toughest thing we have on our plates right now is the fact that we are not identifying this very often. Osteoporosis is a silent disease. Oftentimes we do not know our bones are thin until we fall, and we break a bone. We aren’t necessarily screening individuals with type 2 diabetes for osteoporosis for the reasons I just mentioned, because they don’t necessarily look like they might have osteoporosis. We are not capturing individuals until that first fracture occurs.
As we’re thinking more and more about diabetes, and then bone disease as a complication of diabetes, I think we are starting to recognize it as a risk factor for fracture. When we do that and we go back and pore through some of the data, we’re finding that, yes, individuals with diabetes—10 years are added to their bone life with a complication of type 2 diabetes. For example, a 55-year-old’s bones are more like a 65-year-old’s bones when you add on this layer of type 2 diabetes.
RK: Wow. It seems really important to recognize and even let people with type 2 diabetes know that they are at higher risk of bone disease. Why don’t we talk about this more?
KM: I think it’s important. I alluded to the screening, and one thing that we really struggle with in this population is that we have a lot of screening tests. In medicine and in diabetes, we’ve used things like hemoglobin A1C or fasting blood glucose oral glucose tolerance tests to make the diagnosis of diabetes in patients. In the osteoporosis world, where I live, our screening test for low bone density or osteoporosis is traditionally a scan called a DEXA (dual energy x-ray absorptiometry), a lot of words, which is why we call it a DEXA scan. We use a DEXA scan, which is basically a fancy x-ray where we look at the spine, we’d look at the hip, and generally the data that we get from those fancy x-rays gives us this diagnosis of osteoporosis.
It puts people on a curve based on standard deviations. That data is categorized as normal, osteopenia, or low bone density, or osteoporosis. The biggest challenge we face with type 2 diabetes, and this has now been described pretty thoroughly, is that bone mineral density testing in patients with diabetes is generally normal, if not more elevated than in individuals without diabetes of the same age.
We have a very difficult time screening people for bone disease, with osteoporosis, because our x-rays aren’t working well enough. We’re missing a lot of cases. This has generated a lot of talk as to what’s really going on. If the bones look normal on these DEXA scans, on these fancy x-rays, but patients, men and women, are still breaking their bones, what’s going on? Why are people breaking their bones despite this normal testing? We would ideally like to not have patients have a fracture before they come and sit in my clinic, and we need to talk about treating their bones. Ideally, we need better screening tests, and that’s just under active investigation that’s going on right now.
What do we think is going on? Why are people with type 2 diabetes breaking their bones? There are a lot of different thoughts, and there is no one right or wrong answer. Initially, some of the suspected causes, which are still suspected causes, would be things related to diabetes itself.
Maybe they are falling a little bit more; maybe blood glucose levels are dropping, and people are getting dizzy and falling to the ground, or maybe they have peripheral neuropathy, which is causing them not to be steady on their feet, or retinopathy, where you don’t see as well and you’re more likely to stumble and fall. Those things are not wrong; falls can be increased in individuals with type 2 diabetes mellitus. A lot of these big trials that we look at, where you filter out those risks, we are still seeing this 50 percent increased risk of hip fracture in people with diabetes compared to those without. There is up to a 25 percent risk of any osteoporotic fracture in people with diabetes compared with those without.
Thinking about that, maybe taking those off the table, there’s still this risk. Is there a medication-related side effect that we’re missing? We know that with too much insulin, you can have hypoglycemia, or with too much sulfonylurea, you can have hypoglycemia leading to falls. Thiazolidinediones (TZDs) are medications we don’t use often clinically, but through a cellular mechanism, there can be some bone loss with those medications as well.
There was a bit of rumbling about a category of drugs called SGLT2 inhibitors a few years ago; due to a large clinical trial called the CANVAS Trial, it has been somewhat refuted as time has gone on. So we are using those medications more and more, but again, looking at these same large studies and filtering out patients on those medications, we are still seeing this increased risk. So medications are not the whole story.
What about diabetes complications? Bone is one of them, but there are other organ systems that can be impacted. Kidney disease can thin the bones. Any sort of vascular disease, our bones get a lot of very important nutrients from blood flow. If there’s microvascular damage or macrovascular damage associated with diabetes, the bones inevitably will take a hit and don’t get the nutrients they need, can thin, and become weakened. We talked about the eyes and fall risks, so again, we have to take that into account.
There can be some hormonal factors that we need to think about too. Vitamin D deficiency is more common in individuals with type 2 diabetes mellitus. There can be growth hormone deficiency and certainly insulin deficiency as time goes on with longstanding diabetes. Even gonadal changes—low testosterone, low estrogen, and our postmenopausal women—can impact the bones.
Then body composition—Dr. Kalyani, you’ve done a lot of work in this—looking at body composition as we age. We know we’re going to lose muscle mass. We know we’re going to gain fat mass, but that’s particularly prominent in type 2 diabetes, where there’s probably fat mass where you don’t want it. This is inclusive of the bone marrow fat that can get into the bone marrow and cause changes in bone metabolism. Then loss of lean mass, not only contributing to falls, but bones really rely on lean mass. The push and pull of muscle against bone helps to generate healthy bone; keeping our bones active and rebuilding and remodeling is critical too. So many things at the outset are things we all suspected, and then a whole different category, which I’m happy to get into, is called bone quality, but I’ll pause there.
RK: That was great to hear all the different factors that could really lead to changes in bone and affect bone health.
You mentioned many, including some medications that we use for diabetes, such as TZDs or thiazolidinediones; those include pioglitazone (Actos) or rosiglitazone (Avandia). Then also, the SGLT2 inhibitor, canagliflozin (Invokana), which there has, been a warning, on the package insert for that medication for potential risk of osteoporosis.
It is good to know about all of these risk factors; if you know that you’re at risk, perhaps you can do something about that and be screened for it. I wonder if we could take a step back to talk about the definitions, because I know sometimes, they can get confusing. You mentioned osteoporosis; I’ve heard of osteopenia; you mentioned fragility fractures, and I know that there are other bone diseases that could also happen more commonly in people with type 2 diabetes. I wonder if you could briefly talk to us about what those diseases are and how they might be diagnosed.
KM: Starting with the easy ones, the DEXA scan will spit out a lot of numbers, but probably the ones we pay most attention to would be these things called T scores. A T score is comparing the patient against a 30-year-old. Why would we compare to a 30-year-old? We reach our peak bone mineral density as we age, by the age of 30. The best you’re ever going to get, you’ll have by the age of 30, and a T score is effectively a standard deviation.
A T score of anything greater than a -1 is considered normal bone density.
A T score of anything between -1 and -2.4 is considered low bone density or osteopenia.
Anything less than or equal to a -2.5 T score in a patient is considered osteoporosis.
It’s important we label things, even though, as I’d stated at the outset, individuals with type 2 diabetes mellitus may have normal or low bone density; they can still break their bones. The critical piece of the definition is that those DEXA scores are completely out the window if someone’s had a fragility fracture. I don’t care if the bones are normal on DEXA; I don’t care if they’re in the osteopenia range, but if you’ve had a fragility fracture, your diagnosis is osteoporosis.
Sometimes this can be hard to demonstrate to patients: even though the numbers look great, you broke a bone, you’re at risk of breaking future bones, and we need to do something about it. So that would be your spectrum of normal low bone density osteoporosis.
I mentioned osteomalacia, or softening of the bone. This is when we think about how our bones harden. Bones have different components to them: we’ve got the infrastructure of the bone, the strut work of the bone, keeping our house upright. But to really create good, strong bone, you have to have good minerals in the bone. I think about minerals as the cement of bone; these are things like calcium, phosphorus, and the collagen quality within the bone. Anytime you have deficits or deficiencies in calcium or vitamin D, that mineral, that cement, is soft, and that makes soft bone. You can see where, if there’s any nutritional challenges, if there’s any vitamin D deficiency, a lot of our patients undergo gastric bypass procedures or gastric surgery, where there may be challenges with getting those essential vitamins and minerals. When the cement just doesn’t harden the way that we want it to, we call that osteomalacia, and you can have overlapping processes too. It’s not that you fit into one category or another; patients with kidney disease, all stages, can have alterations or changes in how their bones metabolize calcium, vitamin D, and phosphorus.
The kidneys are really important hubs for how we take in calcium, how we excrete calcium, how we convert inactive vitamin D to active vitamin D, and phosphate handling. As you can imagine, if you mess with that factory, with ongoing kidney disease, you can have abnormalities with all of those important vitamins and minerals for bone health. We can see a lot of changes in bone, ranging from lots of bone breakdown to very little bone breakdown to soft bone with kidney disease.
Then something we’re seeing—I hope less of these days, as we’ve really focused in on glycemic control or glucose control in patients—is when we have longstanding vascular and nerve damage, particularly in the feet, we can see micro fractures and almost collapse of the feet. This condition is called Charcot joint or Charcot foot. This is generally in the setting of longstanding diabetes and some overlap of some of these other conditions mentioned.
RK: It does sound like there are a few conditions that could impact the bone where diabetes is involved. We talked a lot about osteoporosis and perhaps osteopenia, but it’s really good to hear about the other conditions as they can all have significant impairments on mobility and quality of life.
I think what’s sometimes frustrating for patients who develop fragility fractures is when they come into clinic and say, “But I had a normal bone density; my DEXA scan looked normal.” As you’ve mentioned, it can be hard to detect on the routine tests that we use for the general population. With DEXA, where we do see, if it’s 2.5 standard deviations below the norm for a 30-year-old individual, we would call it osteoporosis, but for someone with type 2 diabetes, that might not be the case.
It seems it might highlight the role for ascertaining these other risk factors and screening for them. Is that right? Knowing the limitations of the usual tests that we have, how can we detect those who are at higher risk for these complications?
KM: That’s a great question and certainly a clinical challenge that we all face. I think it all starts with just getting the word out that diabetes is truly a risk factor for bone disease and osteoporosis. I think a lot of us rely on screening tests to tell us what we need to do clinically. So, accepting that diabetes in and of itself is a risk factor, but then also looking at the whole profile, is there a kidney disease that’s been ongoing? Are there medications that might be additionally thinning the bone?
A lot of patients, for example, develop diabetes in the context of other conditions, high-dose steroids for maybe a rheumatologic condition or an autoimmune condition. We know that steroids are hard on the bone for several different reasons, but that should go in the risk factor list in addition to diabetes.
So maybe now you have diabetes, maybe now you have a vitamin D deficiency, maybe now you have low testosterone levels associated with these disease processes, and then maybe you get a family history of multiple fractures, et cetera. What I find most helpful, in addition to just getting the screening test, is to put together a profile of diabetes. Then consider what other things we should be thinking about that ultimately should lead us to worry about fractures or not. Probably the most critical thing is that if there is a fracture, we call it a fragility fracture, if that’s what it is, if we detect something incidentally on a CAT scan. Let’s say you go for a CAT scan because you’ve got some chest pain or you think you have pneumonia, and there’s a spine fracture on that CAT scan. That’s not normal. But really only about 20 to 30 of those actually make it into the chart as an osteoporotic fracture. They get ignored. It’s important for us as physicians, providers, and health care workers to recognize these as real osteoporotic changes, real damage to the bone, and document it as such.
There are little changes that we can make to get a bit of a better sense of fracture risk, even after the DEXA scan. Some doctors will use something called a FRAX calculator. FRAX gives the physician or nurse practitioner an overall fracture risk; a 10-year overall fracture risk, this would be a risk to the spine, the pelvis, etc.
Then a 10-year fracture risk of the hip and using some of the data that comes out of that FRAX calculator. It helps us decide whether or not to start medication for a patient. We can make some adjustments to that calculator because diabetes is not included as a risk factor.
There are other things like age, smoking, steroids, and similar things, but we can make some adjustments to that calculator as simple as checking the box for rheumatoid arthritis. Even if a patient doesn’t have rheumatoid arthritis, you could substitute rheumatoid arthritis for diabetes, and that counts then as a risk factor.
You can actually age a patient by 10 years. I had mentioned earlier that it’s a 10-year accelerated risk if you have diabetes. Sorry if we make you 10 years older, but that gives us a more accurate representation of fracture risk. You’re not taking that DEXA scan at face value. But it is tough, and it’s something we all really struggle with, because by the time they make it to my clinic, usually there has been a fracture, which is, my goal is then to prevent future fractures. But on the front lines, where patients have a lot of different things that primary care providers need to address in the moment, unfortunately, osteoporosis risk slides to the bottom of the list.
RK: The FRAX score that you mentioned, which I know I’ve seen on reports for patients that get bone DEXA scans that I order, is reported as part of the readout. It sounds like diabetes should be considered a risk factor sometime in the future, so we don’t have to make those educated tweaks to enhance or really give a better indicator of the FRAX score. Until we’re there, until diabetes is formally included, it does sound like it’s really a holistic assessment of both risk factors and using these different tools to inform clinical care. As you mentioned, people with diabetes are at higher risk of falls already; because of that too, they would be at higher risk in addition to the bone disease of developing a fragility fracture. Just to contrast that, the other type of fracture would be a traumatic fracture, is that right?
KM: That’s right. So that would be falling from a two-story building or a car accident. If it sounds like anyone would have broken a bone in that circumstance, your 15-year-old child or a 25-year-old college kid, whatever the case may be, is this normal, or is this not abnormal? Sometimes we torture patients by trying to get down into every detail of how the fracture occurred. It is important to understand those fractures to decide if it’s fragility versus traumatic, because that is going to dictate a lot of times, if you’re going to start treatment and how deep a dive you go into workup for other causes of bone loss.
There are a lot of questions around fractures, but it absolutely should be part of the intake assessment in your endocrinologist’s office or in your primary care doctor’s office. If there is a history of fracture, that is a traumatic or a fragility fracture; those should be taken very seriously. To impress upon people how serious this is—it is like someone has had a heart attack and not getting the details of a heart attack. You want to know the details because you don’t want there to be another event down the road. It is important to get the details and treat them seriously because the worst-case scenario is there’s another one on your watch, and the patient outcome is poor in those more common scenarios that we think about.
RK: It sounds like if you’ve had a fragility or a traumatic fracture in the past, detected incidentally on a radiographic scan, or you present to your healthcare provider with a fracture, that you’re at a higher risk of a future one. Is that what you’re saying?
KM: Absolutely two to three times higher within the first year. If you catch it, and you identify it as an osteoporotic fracture, it’s important to intervene on that fracture to make sure there are not future ones. As you said at the outset, Dr. Kalyani, this is a very important disease.
That’s the other thing, I probably even should have led with this, but osteoporosis is a big deal. We talk about numbers; we’ve just spent a lot of time talking about T scores and DEXAs and using all this sophisticated terminology, but why do we care about osteoporosis? In fact, in clinic, it’s what I always lead with patients: why are we even talking about this?
Fractures, they’re not fun; nobody wants to break a bone, but the problem with fractures is what lies down the road. These are things like pain, immobility, and the complications that come from pain and immobility. We think about blood clots, we think about weight gain, we think about loss of just the things you enjoy doing in life, loss of independence. Then in addition to all of those immediate issues, surgery, infection, risk, et cetera, a lot of times those things can culminate in increased morbidity and mortality. It’s the mortality piece. For example, within the first year of a hip fracture, there’s up to a 30% risk of death for patients, which is rivaling stroke data and heart attack data. We have to take these fractures very seriously because it’s not just an inconvenience; it can be something that leads to someone’s death at the end of the day. Unfortunately, a lot of our patients know people or have heard of people who’ve had a hip fracture, and then within the year, they’re no longer with us.
Again, thinking about osteoporosis and bone disease in the same serious way that we think about heart attacks and strokes is very important; we need to get the word out that this is something we should be asking about, screening for, and treating if we identify these fragility fractures.
RK: Thank you for going over the “why do we care?” There are lots of reasons to care, and I know you and I have both seen, unfortunately, the devastating consequences after a hip fracture, a spine fracture. There can be a downward spiral, especially if you have other medical conditions or aren’t able to bounce back as fast. It is a long road for some people to rehabilitate and get back to their baseline if they’re able to, which is all the more reason to prevent these from happening in the first place.
Really what we’re talking about here today includes quite a few risk factors that can lead to bone disease. I wonder, specific to diabetes, you’ve done a lot of research in this area too, but what about blood sugar levels and management of diabetes? How does that impact bone health? You mentioned bone quality before, so perhaps you can talk a little bit about that. What do we know about the role of glycemic management in protecting our bones?
KM: That is a great question because it’s that next step in how we think about bone because I said at the outset, we’re missing something. The fact that the bones look pretty darn good on DEXA scan, the amount of bone that we see on DEXA scan, is falsely reassuring. So, we feel good about the scan, but patients are still going out and breaking bones. That’s bone quantity. That’s how much bone you have. It’s that fancy x-ray that says you’ve got X amount of bone, and it looks sufficient.
The second step that we have to think about is bone quality. So not just how much bone you have, but how good is that bone? I use this comparator all the time; a lot of us have heard the story of The Three Little Pigs, and you have one pig, and he’s got a ton of straw. It’s a whole ton, but it’s straw, and then you have another pig who’s got a ton of brick. Both have tons of material, a ton of straw, and a ton of brick. They both build a house, but when the wolf comes along, which one do you want to live in? You want to live in the brick house. That’s quality, right? Is it straw or is it stone? What we are speculating in the field, and there’s been a lot more research going into it, is why might diabetic bones or people with diabetes in their bones—why might they be more like straw? Quantity looks pretty good, but not so great quality as opposed to stone.
What has happened? What are some of the factors contributing to that? This idea of bone quality has, depending on who you talk to, a million different definitions. There are different things we think about, so we think about how the bone is laid out. The architecture, or the microarchitecture, of the bone, the strut work, you peel back the drywall—what do the walls look like behind the scenes? Is it different in diabetes compared to those without diabetes? The answer is “yes.” There are differences in microarchitecture; there are differences in how the hip bones are laid out, something called geometry. It’s if you think about it in architectural terms, and now in engineering terms, the geometry of the bone is different; there’s a point parameter that we look at; oftentimes it’s how actively the bone is remodeling. Our bones are always building up and breaking down. They are not like rocks that we’re walking around in; our bones have to renew and refresh themselves, like our skin. If we didn’t shed the old skin and put in new skin, we’d look pretty gnarly. Bones are always remodeling. Is that recycling process and bone different in those with diabetes compared to those without? The answer is yes, diabetes impacts how actively and well bones rebuild and refresh themselves to keep them flexible. It’s a lower rate of remodeling, so bone gets old and brittle as time goes on.
When we really look deep down inside the bone—even beyond that microarchitecture I just talked about, peeling back the drywall and looking behind the walls, really looking at the composition of the bone—that collagen, that mineral we talked about, is there something different about it that’s disturbed with diabetes? The answer there too is yes. When looking at mineral content and looking at collagen formation, there are differences there in diabetes. In part, a lot of this may be due to advanced glycation end products (AGE) deposition. We’re measuring it every time we get that hemoglobin A1C; these circulating AGEs. They actually do get deposited into the bone, and they can cause disruptions in or problems with how the bone is laid out, how flexible the collagen is, and how well the mineral is deposited within the collagen to harden. Those AGEs play a role in how strong bones are. That quality piece again, just like the beginning, there’s a million different reasons why people with diabetes may not have perfect bones. There are quite a few reasons we’re investigating actively as to why the quality of the bone might not be so great.
How does all of that translate into what we do about this? If we suspect that with longstanding disease, or as you have diabetes longer and longer, you have more problems with bone geometry. You have more problems with bone microarchitecture. You have more problems with bone remodeling. You have more problems with bone minerals, more problems with AGE accumulation, or deposits within the bone. You can imagine that the less severe your diabetes, the better glucose control you have, the fewer AGEs you have circulating, and the lower your hemoglobin A1C (or getting it down), the less damage can occur over time. Osteoporosis is not an overnight phenomenon. It happens over many years. So if you can slow that weakening of the bone with better glycemic control, keeping control of your blood sugars, keeping a healthy active lifestyle, exercising, good nutrition, and calcium and vitamin D, you can see that at the end of the road, it’s only going to be beneficial to the skeleton.
RK: I really like that analogy of The Three Little Pigs and the straw. When I think of a bushel of straw or a straw hut, you can imagine how easily it would fall compared to a ton of stone with a building or house, which would be more solid. I think that’s a great way to think about the fact that even though there’s a lot of building material, the building material has to be strong itself. You mentioned those AGEs, which are really just the circulating glucose sticking to proteins and sticking to areas in the body where it shouldn’t. It sounds like the higher the glucose, the longer you’ve had diabetes, the more likely it is that higher glucose in the blood can stick to places where it shouldn’t, such as the bone, and make it weaker. Underscoring again the importance of keeping those glucose levels at target, so that’s really good to know.
You talked a little bit about the symptoms and signs of osteoporosis. I wonder if we could move now to talking about how people might know if they are having bone disease or a fracture. Then maybe talking a little bit about some of the treatments that we commonly recommend for people who have bone diseases.
KM: Osteoporosis is a really tricky one, Dr. Kalyani, because, again, like plaque building up in your arteries or brain issues, this is a silent disease. A lot of times patients will come in and they think that I’m going to be treating them for their knee pain or their shoulder pain or their back pain. I say, “Oh my gosh, I’m sorry you’re having pain, but that’s probably not osteoporosis because osteoporosis is generally silent with all of these changes happening underneath the surface of the bone until that fracture occurs.” Then if there’s a broken bone, you’re going to feel that, although not all the time; 50% of vertebral fractures or spine fractures, we don’t even know about until we get an image. There may have been an episode of some back pain a couple of months ago, and you don’t know about it until you get a CT scan later, and there it is. So, osteoporosis in and of itself tends to be a silent disease.
Now sometimes we can develop thinning of the bone in diabetes and other conditions as well due to nutritional abnormalities. If you are not getting enough calcium, if you are not getting enough vitamin D, or if you have protein abnormalities or malnutrition in general, you can have side effects due to that. You can have softening of the bone and bone pain, particularly in your lower legs or in your upper legs. If you press on the surface of your bone, if it truly is soft, sometimes that is painful. I always press on the fronts of people’s shins as a part of my physical exam. Some patients will actually jump, and sure enough, we’ll get a vitamin D level or check their calcium levels, and those levels are elevated. That could be something that pops up every now and again with bone pain. I would say other symptoms of osteoporosis outside of a fracture are pretty limited. Sometimes patients have a risk for kidney stones that can thin the bones. If you’re having back pain or blood in your urine, we look for kidney stones, but on the whole, it’s tough. It’s a very silent disease, so they don’t come into my office again until oftentimes a fracture has already occurred.
RK: As you mentioned, it can be a silent disease. It sounds like more often than not, people might not have symptoms; is that right? And people really need to be screened.
KM: Yes, and that’s the critical piece: screening. I’m thrilled that the American Diabetes Association is partnering with our bone groups to really work on incorporating bone health into the guidelines. It’s a thick guideline, but we have more than a word or two; we have this whole section now on bone disease and diabetes to try to raise awareness that this is part of the screening, much like you would think about cardiovascular health or ophthalmologic evaluations, getting your feet checked, your eyes checked, et cetera. You at least have to do a baseline bone density test and ask about fractures in that screening process because it is so asymptomatic.
RK: Do you think most people with type 2 diabetes should have a bone density or DEXA test at some point, and if so, when might you recommend it?
KM: Yes, that’s a great question, and the answer is yes. It is definitely a risk factor; diabetes is a risk factor for bone disease. Whereas without any risk factors, it’s generally recommended that women older than the age of 65 get a DEXA scan, men generally older than the age of 70 or so. With any one risk factor for bone disease or fracture, diabetes again being one of those, we generally are screening women around the time of perimenopause, when we’re otherwise losing a lot of bone due to estrogen declines. Even men around the same age should at least have a screening bone mineral density test to know where the numbers are starting. Even earlier than that, if there’s a fracture, that would prompt you to get the scan sooner, if there’s a fragility fracture. Again, if we include diabetes now in the list, like we would rheumatoid arthritis or steroid use or family history of a hip fracture, we should be screening earlier than those 65 years of age for women and 70 years of age for men, it should be part of your initial assessment.
RK: One of the questions that I feel comes up sometimes, in clinical practice, is having a family member who’s had a fracture and how that might increase someone’s risk of having a fracture. I wonder if you could talk a little bit about that too.
KM: That’s a good question, and in that FRAX calculator we were discussing earlier, it is included as one of the check boxes that you can select. Genetics are a huge component of bone health. Maybe 40% of our predetermined bone mineral density that we get again by the age of 30 is really a part of our genes. So if you have a family history of osteoporosis or a family history of fracture, maybe you didn’t get to your peak bone mineral density by the age of 30. Maybe instead of getting to the 10th floor, you only made it to the 7th floor. That is something that should be discussed, in addition to other risk factors. It’s not just diabetes—”Are you on steroids? Do you have a history of kidney stones or a family history of fractures?” These are all things that go into that melting pot of fracture risk assessment that ideally your primary care doctor is getting. But, when I hear a family history of fractures, particularly hip fractures, or a lot of patients will describe, “Mom just got shorter and shorter as she got older,” or “Dad got shorter and shorter as he got older,” or “They got that hook in their back.” When I hear things like that, it really does make me wonder if maybe this person is at even more increased risk than I initially thought.
RK: Do some relatives confer higher risk? For instance, I know we often talk about maternal or having a history of fracture with your mother as something that we think about as a risk factor. But is there any relative who’s had a fracture that confers higher risk, or do certain relatives make it more likely that you will?
KM: Yeah, it’s mom and dad; they’re first-degree relatives. This is one disease state where I feel like we do neglect men to some extent. We don’t think about men as getting osteoporosis, but they absolutely do. So, either parent, if there’s a history of fracture or, again, getting shorter with age or multiple fractures that are, again, fragile, not car accident-related, that should be considered. Then I always ask actually about brothers and sisters too, because sometimes we don’t know our parents’ history for whatever reason. Maybe there’s adoption, or maybe there was an early passing of a parent, or they just didn’t make it to the point in age where they may have had a fracture. But if I get a history of a brother or a sister who’s had multiple fragility fractures, I take that into consideration as well. So it’s any first-degree relative, although in the FRAX calculator it asks very specifically about parental history of hip fracture.
RK: That’s really good to know and important to know the family history to know whether any of your first-degree relatives, parents, or siblings have fractures. Now, for those people who are listening and are interested in how they can prevent having bone disease, such as osteoporosis, and having fractures in the future—what are some lifestyle modifications or lifestyle measures they can take to optimize their bone health and really ensure that they have strong bones for their lifetime?
KM: As the first visit in my clinic comes to a close, it always comes out, “Hey, what’s next? What do we do?” I always lead with what you, as a patient, can do to improve your bones. I can pull out my prescription pad until the cows come home, but it really is a partnership because it’s not just about medication. It’s about all of these other factors we’ve gotten into today.
Starting with a healthy lifestyle. I know that’s a term that’s very broad, but it is critical. These are things like exercise; we know the benefits of exercise to blood glucose control. Guess what? Exercise is really good for your bones too. We say resistance training, and that doesn’t mean you need to go out and you need to get a gym membership and pump iron 8 hours a day. Resistance training can be. A 30-minute walk around the block on a nice day, and finally the weather is getting a little bit nicer so we can get outside a bit more. A nice walk around the block, exercise bicycles are great. Even elliptical trainers are great. Using the arms, there is so much free content now on the computer that you can get access to; you can go in, and you can use your search engine to look into osteoporosis or bone-building exercises, and you don’t need a fancy gym membership. You maybe just need a couple of heavy cans at home that can give you the exercises you need. This includes even exercises for people who have functional limitations.
You can do things sitting from a chair; you can do things just with your legs, and you have to do things within your boundaries. But we generally recommend 3 to 5 days (a week) of 30-minute sessions of resistance training in some form. The only thing that really doesn’t count is swimming. It’s still good for your heart and other things, but swimming may not be as good for the bones because it doesn’t provide that muscle against bone that we need to build healthy bone. Exercise is very important. In that same breath, it’s interesting because for blood glucose control and really to optimize your blood sugars, make them the best that they can be. Weight loss is generally recommended in patients; if weight is contributing to glucose control, I always like to counter that with healthful weight loss.
In my world, if you lose too much weight too fast, you can also lose bone with that because really fast weight loss makes us lose lean mass. Again, Dr. Kalyani, you know all about this too, but when you lose a lot of lean mass or muscle mass really quickly, you can lose bone. We do have a special eye on individuals who undergo gastric sleeve procedures or Roux-en-Y gastric bypass (RYGB) procedures. Just to make sure they’re not losing bone, and unfortunately through studies, we know that they do. Prioritize healthful weight loss through exercise and healthful diets.
What can we do in our diets to really improve our bone health? Getting ample protein, you got to start there. Remember I said bones are made of collagen. Guess what? – Collagen is protein. So, you’re depriving yourself of collagen; protein does not have to be meat. It can be plant-based as well. Intake adequate protein for someone of your height and your weight. As well as adequate calcium intake. Generally, for individuals at risk for osteoporosis, fracture, or bone loss, we recommend about 1200 milligrams of calcium total per day. Ideally, you get it through your diet. I think the cardiologist would prefer that. I know our heart specialists, our kidney specialists, would prefer that, but it is not always possible to get it through the diet. Sometimes patients are lactose intolerant, or they just don’t like cheese, but there’s plenty of other non-dairy sources out there, too, like fortified non-dairy milks, for example, where you can get calcium. Every once in a while, and certainly in my practice, you must oftentimes turn to a supplement, and there are calcium supplements out there that are well tolerated. But again, that 1200 milligram-a-day goal would be what you would strive for. Along with adequate vitamin D levels. The endocrine society would recommend a vitamin D level greater than about 30 nanograms per milliliter for patients at risk for fracture, which again, patients with diabetes are at risk. So, getting enough vitamin D, and that can range all across the board, Dr. Kalyani, and I’m sure you’ve seen it too. Some patients need 2,000 a day, some patients need 5,000 a day and some patients need prescription strength. So really that would be something to work on with your provider to decide exactly how much you need to meet that 30 nanograms per milliliter threshold.
As far as other things with lifestyle, guess what? I’m going to be yet another doctor telling you, please don’t smoke; please don’t drink too much; please do try to avoid toxins that might otherwise harm the rest of your body too. Then don’t neglect those other areas of your health. We said kidneys can affect the bone and vascular damage can affect the bone. This is—I know it’s annoying—I’m adding one more thing to think about, right? With all of the other pieces of this complicated disease state puzzle, I’m adding one more and saying we have to think about your bones. But guess what? In treating all those other things, hopefully you’ve been doing as best you can. You’re ultimately going to do good by the bone as well. Managing your blood pressure, managing your cholesterol, and taking good care of your kidneys—all of those things, at the end of the day, will trickle down and have a good impact on bone health too.
RK: I think it’s great to hear about a variety of ways that people can choose—whether it’s through exercise, which they should definitely exercise, or also through different types of foods and maintaining adequate intake of protein and calcium and vitamin D—to keep their bones strong. With the addition then of not drinking and not smoking.
What about the consumption of sodas or the consumption of sugar-sweetened beverages? How do they, or do they, affect the bones in any way?
KM: They’re not the best, right? I think sugar. It tastes good. I love a good gummy bear every now and again. But, no, it’s not good for bone health.
It’s not just carbonation. There is a lot of information out there about carbonation and its impact on bone health, which is not the best data. I find that the problem with sugary sodas, and sugary drinks in general, is they tend to replace more healthy choices. Instead of having a glass of almond milk, if you reach for a sugary beverage instead, you’re depriving yourself of the nutrition that might otherwise come from that glass of almond milk.
Then again, getting back into this discussion of those high blood sugars and then what that does with these advanced glycation end products (AGEs) that then go and accumulate in the bone, causing increased fat production within the body, and that is bad for bone health.
There are a lot of downstream effects of all of that sugar too, which have immediate and long-term effects on bone health and bone strength. I know it tastes good, and no one is saying never, but at the end of the day, the less you drink sugary drinks, or carbonated beverages with lots of sugar in them, probably the better off you’ll be. This is not only from the diabetes standpoint, Dr. Kalyani, but certainly from the bone standpoint as well.
RK: Yeah, it definitely can have wide-ranging benefits to moderate or reduce sugar-sweetened beverage consumption. I think the point that you made about weight loss is really important because we do often, knowing that obesity is a risk factor for type 2 diabetes, talk about weight loss with many of our patients with diabetes. As you mentioned, it can have potentially adverse effects in both the muscle and the bone. Knowing that ahead of time is important to counteract potential adverse effects by doing exercise, by ensuring that nutrients are in the diet to protect the bone as well. The post-bariatric bypass population, or those who undergo weight loss surgery, certainly are at the highest risk, wouldn’t you say, of those bone deficiencies?
KM: They are, and we have the data to show that not just with DEXA but also using some more sophisticated imaging techniques. I think what we’re all struggling with is, beyond the immediate weight and bone loss, the long-term benefit of those surgeries: Does it still outweigh the skeletal question marks that we have, and can your bones regain strength over time?
We don’t know the answers to that. I think, again, it’s why that nutritional counseling piece, not only prior to the surgeries but also ongoing nutritional support following the surgery, is very important. So that the vitamin D levels don’t drop and there’s adequate calcium intake. We know there’s malabsorption with a lot of these surgeries where the body just doesn’t absorb nutrients as well as it should, either because the stomach is a fraction of its original size or because the intestines have been rerouted and you’re not supposed to absorb things any longer, but really continuing to partner with someone educated in nutrition to prevent some of that inevitable bone loss that will occur.
One thing I do want to circle back to, because I’ll kick myself later if I don’t bring it up, is another reason that exercise and maintenance of muscle mass are so important: so that we prevent falls. I have spent so much time, probably more recently than ever, feeling like I’m surrounded by people who fall. My father is a “faller”; my mother-in-law was a “faller.” So, I’m always thinking about these things. My father has had type 2 diabetes for over 20 years now, and so he’s got a whole host of complications with neuropathy and vascular issues. He now falls, and I worry every day about him taking a tumble. You better believe I’m all over him about doing his physical therapy and eating his protein and continuing to strengthen his muscles so that he doesn’t topple and so that his bones aren’t challenged. People fall, and they don’t always break bones, but I say, “Listen, stop testing your bones. Let’s just not fall to begin with.” So not only exercise, but glucose control to the point where your blood sugars are well controlled, but not too low either. We know we fall when we get woozy, and certainly my dad has had a couple of those episodes too. Avoiding the low blood sugars too, because that can get patients into trouble as well.
RK: Thank you for sharing that. The scenario you described with your father, unfortunately, I think is more common than we realize, and he, of course, benefits from your expertise in this area, but the link between falls and fractures can’t be underscored and then you add diabetes to that. It’s almost like a triple threat. Perhaps those who do fall or feel unsteady on their feet should think a little bit more about protecting their bone health. Wouldn’t you say, because of that risk?
KM: Absolutely. Not to terrify people, I don’t want people to feel like they’re Humpty Dumpty out there. We don’t want to wrap anyone in bubble wrap before they go outdoors, but just to be mindful of it. Frankly, if it motivates you to take that extra walk around the block or to go to that physical therapy session that your provider’s been recommending out of concern that maybe you are a fall risk—if that’s the motivator that you need—then by all means, take this talk that we’ve had today and use it as yet one more reason why you should be exercising.
RK: I fully agree. I can’t underscore the importance of prevention. We focused a lot today on talking about the prevention of bone disease and how to diagnose bone disease. I don’t think we need to go into large detail about the treatments that are available, but I wonder if you could just say a few words about how good the treatments are that are out there and what people should do if they’re interested in getting diagnosed or identified for this and potentially getting treated.
KM: Yes, absolutely. This is where the prescription pad comes into play beyond lifestyle and diet and exercise and what have you. Sometimes we must pull out our prescription pad; if there’s been a broken bone and we’re worried about future broken bones, we’re going to be more inclined to do that. Or if the numbers don’t look so great on the DEXA scan, or if there are so many risk factors we worry about, we’re waiting too long before we prescribe a medicine. You’re right, Dr. Kalyani; there’s a whole buffet line now of osteoporosis medications that we use, ranging from pills that patients can take once a week or once a month. There are infusions, where you get an IV and you get a treatment once a year, which can be pretty convenient for patients. There’s injection therapy that’s given twice a year and even bone-building medications. In some patients, a lot of the pills and infusions and injections really prevent the bones from breaking down, and they’re our go-to medications in a lot of situations. But if we’re really worried about patients and patients, maybe there have been multiple fractures, or their numbers may actually be low, or there are other things at play. We may turn towards a category of medicines that really build the bones back up again. That part of the decision-making process is highly individualized. It involves looking at a lot of different factors, ranging from other diseases that may be on the list to other medications to patient preference.
I find that the most important thing is that I can recommend daily injections. One of the bone-building medicines is a daily injection, but you may be tired of daily injections, or maybe you’re not on insulin, and you have no intention of starting daily injections if you don’t have to. That’s where the partnership comes into play and talking about shared goals, because medicines are only successful if you actually take them. So again, that part of it does come to pass sometimes if there’s been a broken bone or progression of osteoporosis, and they all work.
We’ve had some studies looking at the effectiveness of these different types of osteoporosis drugs in individuals with type 2 diabetes, and we know they do work to prevent fractures. So, beyond that, it’s just a matter of coming up with the right drug or drugs, and if they don’t work, sometimes we must pivot and try something else. There are lots of options out there, again, in addition to the calcium, the D, and the lifestyle interventions, because it’s always a teamwork approach to really optimizing and improving bone health and strength.
RK: Dr. Moseley, this has been such an informative discussion. I know I’ve learned a lot, and I’m sure our listeners have learned a lot, too, about the higher risk of bone diseases in people with type 2 diabetes, some of the challenges of diagnosing bone diseases using some of the routine measures, such as the dexamethasone and bone test, and really the importance of screening for risk factors, including family history and other lifestyle factors and other medical conditions that might raise someone’s risk of having bone disease, and then knowing that if medication is needed, it’s reassuring to know that they are effective often in preventing a fracture.
I wonder in parting if you have any last words for our listeners who, after hearing this discussion, are empowered to really try and do their best to preserve their bone health. What would you recommend that they do as next steps?
KM: This, just listening to this podcast and learning about this, is the most important step. As I have stated, part of what I like to do most is get the message out there that this is something we should be thinking about: bones, bone strength fractures in people with type 2 diabetes, that it is a more recently recognized complication of diabetes that sits on that list with eyes and feet and heart and kidneys.
Bones are now on that list too. By understanding that we have to now consider bones as patients, we can go to our providers and say, “Should we maybe talk about my bone health? Should we maybe screen me for my bone density to see if there’s anything that we need to maybe intervene upon?” I think that that’s very important.
Educating patients so they can maybe go and educate their providers a little bit more. And I think it’s again, one more reason, in understanding the importance of bone health and its association with type 2 diabetes. It’s one more thing to motivate patients to do all of those elements that really are critical for improving blood glucose levels or blood sugar levels: the diet, the exercise, and healthy lifestyle choices. We’re all working towards the same goal. Luckily, there’s so much overlap with what patients can do to improve their health with bones, heart, kidneys, and overall wellness. I think that, very luckily, it’s just one more motivator for them to make the right choices in life.
RK: Dr. Moseley, thank you so much again for your time today and sharing your expertise. We truly appreciate it.
KM: Thank you so much, Dr. Kalyani.
RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit hopkinsdiabetesinfo.org.
We love to hear from our listeners. The email address is hopkinsdiabetesinfo@jhmi.edu.
Thanks for listening. Be well and see you next time.
- Home - | - Episode 42: Hospital Management of DiabetesIn Episode 42, Dr. Kalyani welcomes Dr. Andrew Demidowich. Chief of Inpatient Endocrinology at Johns Hopkins Howard County Medical Center and an Associate Professor of Clinical Medicine at the Johns Hopkins University School of Medicine. He completed his residency training at the Mount Sinai School of Medicine in New York City and his fellowship at the National Institutes of Health in Bethesda, MD. Dr. Demidowich has published over 50 peer-reviewed articles, and his research interests include elucidating the relationship between obesity, inflammation, and diabetes, as well as strategies to improve diabetes care delivery in the inpatient setting.
Download TranscriptPodcast 42: Hospital Management of DiabetesDr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani at Johns Hopkins. We developed this podcast as a companion to our patient guide to diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org. For today’s podcast, it is my pleasure to introduce Dr. Demidowich, who will be speaking to us about hospital management of diabetes. Dr. Andrew Demidowich is the chief of inpatient endocrinology at Johns Hopkins Howard County Medical Center and an associate professor of clinical medicine at the Johns Hopkins University School of Medicine.
He completed his residency training at the Mount Sinai School of Medicine in New York City and his fellowship at the National Institutes of Health in Bethesda, Maryland. Dr. Demidowich has published over 50 peer reviewed articles, and his research interests include elucidating the relationship between obesity, inflammation, and diabetes, as well as strategies to improve diabetes care delivery in the inpatient or hospital setting.
Welcome Dr. Demidowich.
Dr. Andrew Demidowich, MD: Thank you for having me. It’s an honor to be here.
RK: We are so excited to learn from you today about how diabetes is managed in the hospital and how it might be different than how people manage their diabetes at home. I wonder if you might start off by telling us: why would someone with diabetes need to be admitted to the hospital in the first place?
AD: People might need to go to the hospital either for diabetes-related issues such as very high blood sugar or very low blood sugar—we call those diabetic emergencies. Very high blood sugars can sometimes lead to diabetic ketoacidosis, which is when the body is no longer able to utilize glucose or sugar from our blood to use as fuel or energy for our body.
It then has to go to our backup generator—fat—which we carry around every day, sometimes too much, unfortunately. Our body starts breaking down that fat as a backup energy supply to feed the organs of our body. But when you break down fat, it turns into fatty acids. It eventually acidifies the blood and becomes a potentially life-threatening condition, which requires hospitalization and urgent treatment.
Also, people with diabetes might need to be hospitalized for completely different reasons, such as anything else that other people without diabetes might be hospitalized with: heart attacks, strokes, pneumonias, kidney issues, infections, the whole gamut. Diabetes might be a secondary issue to the cause of their hospitalization, but it is still very important to be managed correctly once they are in the hospital.
RK: It does sound like there could be many reasons why someone with diabetes might need either a short or a long term stay in the hospital. You mentioned what we call diabetic emergencies, such as diabetic ketoacidosis hypoglycemia, even hyperosmolar hyperglycemic crisis. We had a previous podcast talking about those issues in detail, I appreciate you bringing those up.
You also mentioned the other common reasons people get admitted into the hospital that might also occur in someone with diabetes. Are any of those types of admissions, you mentioned pneumonia, for instance, more commonly seen in people with diabetes?
AD: Yes, exactly, the higher your blood sugar is, the more complications you can develop for several reasons. Not only is sugar fuel for our own bodies, but it’s also fuel for bacteria, viruses, fungi, and things that really shouldn’t be living on or inside of us. By having higher blood sugar levels at home, you are at increased risk of developing some kind of infection, such as pneumonia or urinary tract infection or something to that effect.
We also know that sugar is sticky. On the outside, I say to my patients, “Honey is sticky, bubble gum is sticky, caramel is sticky, but indeed, inside our bloodstream, sugar is also sticky.” Now, the medical term for it is called glycosylation, where the sugar molecules actually stick to things inside our body, like our blood vessel walls or our immune cells. By having those immune cells coated with sugar, they’re unable to actually defend our body as much, but this also causes increased levels of inflammation, particularly in our blood vessels.
People with uncontrolled or poorly controlled diabetes are at increased risk of other medical issues such as heart attacks, strokes and nerve damage, which could then lead to issues with vision or falls and unfortunately then therefore leading to fractures.
That is why both in the inpatient and in the outpatient space, the clinicians focus so much on good diabetes control, because just having diabetes per se doesn’t increase your risk for many of these things. It is more dependent on whether or not the patient’s diabetes is poorly controlled, in which case the risk truly elevates. But for people who have really well-controlled diabetes, I always tell my patients, “You can live a long, healthy life just the same as the person next to you.”
RK: I agree. I think it is so important to emphasize that following routine preventative care measures and really striving towards whatever metabolic goals are discussed with you and your health care provider on the clinic side can really prevent some of these complications from occurring, including hospitalization.
You mentioned the terms inpatient and outpatient; could you define those for our audience? They are used very commonly but may not be so well defined.
AD: Unfortunately, as clinicians, we tend to fall into medical jargon, and we don’t even realize that we use it. I do recommend to all my patients, “If there’s anything that you don’t understand while I’m telling you in our face-to-face interactions, please do not hesitate to stop and interrupt me and ask me. There’s no such thing as a stupid question.” But yes, to your point, inpatient typically means in the hospital setting. Whereas outpatient really means out of the hospital setting, it really means in the clinic when you’re seeing your doctor for a regular checkup or appointment.
RK: There are also urgent care centers and emergency room settings. Where would you classify those?
AD: We would consider those as technically outpatient. So emergency care, urgent care settings, and even what we call the observation unit, insurance companies still define those as outpatient areas. Even though physically you may be inside the hospital. They have made a delineation that you’re not admitted to the inpatient setting, which supposes that you will need a higher level of care and more than one night in the hospital to help treat and resolve the acute medical issue that brought you to the hospital in the first place.
RK: That is an important distinction to keep in mind. If you go to the emergency room, you may be in a hospital, but really what we’re talking about today on the inpatient side is when the healthcare team thinks that you need to be formally admitted and perhaps actually have a bed where you stay for a day or longer because of the type of medications and other regimens that are required. What kind of specific regimens, in general, might someone require in the inpatient setting that they can’t get at home, for instance, getting an intravenous medication? Sometimes that can be given in the ER as well. Why would someone need to be in the hospital to get these treatments?
AD: Typically, once patients are admitted in the inpatient setting in the hospital, we manage diabetes almost exclusively using insulin. Whereas in the outpatient or out-of-the-hospital setting, people frequently are on all sorts of other medications, like pills, such as metformin or glipizide, or the new injectables like semaglutide (Ozempic) or tirzepatide (Manjaro) that we’ve been hearing a lot about. The issue with those medications is that many of them are really wonderful medications, but of course they have potential side effects or nuances of whether or not they’re safe to use if someone has acute kidney or stomach issues.
Insulin is a natural hormone that our body produces and is therefore the best, most well-studied, and most predictable in terms of its action. We know it plays well in the sandbox, no matter what other medication that another doctor might want to give you or any other procedure that you might need to undergo. I do not have to worry when I use insulin about whether or not someone’s going to go for imaging, a CAT scan with IV contrast. Are they going to go to surgery? Are their kidneys not working? Or is their liver having difficulty working? In any of those situations, insulin is safe to use, whereas other oral medications might become unsafe. In order to ensure the safety of our patients, sometimes we’d like to just keep it simple and just switch everybody to insulin.
RK: That’s such an important point to emphasize. I often hear from my patients, and I’m sure you do too, “Why do my medications have to change? Just because I’m in the hospital for a day or two?” Emphasizing this unpredictability of what can happen when you have an acute issue going on, even if it’s not directly related to diabetes, is important because the regimen itself needs to be flexible enough to accommodate having to be without food overnight, for instance, before a procedure, or if there are changes in the kidney and liver function. Like you mentioned, many of these medications, particularly the pills, may be metabolized.
I think understanding that the predictability, or unpredictability, of being in the hospital setting is really what necessitates these changes. But it can be confusing for patients who are well managed at home; maybe they get a bad infection that requires hospitalization, and then suddenly, after years and years of being on their medications, they have it flipped to insulin. What do you see in the hospital setting when patients come in and are asked to put on insulin?
AD: The most important thing is having discussions with patients and setting expectations and answering questions. Typically, once they have a conversation, exactly like we’re having, almost all patients are understanding and agreeable. There’s a common misconception amongst patients that if you start on insulin, you are doomed to be on insulin for the rest of your life. There are some patients that are very hesitant to be started on insulin, even just temporarily in the hospital setting, because they think that, “Oh, if I started insulin, that means I have to go home on insulin. I can no longer be on my pills, which I do really well on, ever again.” That is a complete misconception. People who are on insulin in the hospital oftentimes are able to restart their home medications on discharge. It is during that brief stay at the hospital that we want to keep you as safe as possible, so we usually just use insulin just during that time frame.
RK: Thank you for making that point. I think that’s a great way to describe it: a temporary change to the regimen that may or may not persist after you go home, depending on the reason for why you were admitted to the hospital in the first place. Part of the reason we’re having this discussion today is because that new setting of being in the hospital does require some changes for almost everyone who has diabetes, regardless of the regimen they’re on. Wouldn’t you say that’s true?
AD: Yes, not only that, but the hospital setting is an opportunity to reassess how everything is going at home. For people who come in and their A1C is at target, which is roughly around an A1C of 7%. We say roughly depending on the person and their comorbidities. There are opportunities to reassess. Some people come in only on pills, but their A1C is 11 or 12%, and you have that conversation of, “Maybe we do need to start some insulin when you go home.” Or at the very least, “Let’s look at what your current regimen is and how we can improve it.”
Some people come in with hypoglycemia, meaning that their blood sugar is low either due to insulin or due to another class of oral pills called sulfonylureas. We might then have the discussion of, “Hey, maybe this is not the best type of medication for you. Once you leave, we can put you on a different class that does not cause hypoglycemia, such as Ozempic, Manjaro, or Metformin.” Of course, that is the thing that I enjoy so much about diabetes management: there’s so much nuance, and it is a little complicated, but at the end of the day, I also really enjoy having these conversations with my patients. Ultimately, they are the ones who will live with this for the rest of their lives. I really find that shared decision-making is very important to come up with a strategy that allows them to set themselves up for success and understand how they define success.
RK: I think that’s a great way to describe it, as an opportunity for a tune-up for people who may, for whatever reason, not have had their regimen optimized. It presents an opportunity to focus on what the tweaks are that we can make to get you on a regimen that will eventually help you reach the metabolic goals set by your provider, even when you go home. I think, for a subset of people with diabetes, a hospital admission can be a great opportunity to improve their care. In your experience, having really managed many people with diabetes in the hospital, how many of them go home on the same regimen they came in with to really have a change in the regimen on discharge?
AD: I would say it is 50/50, which means that there are still quite a large number of people where there is an opportunity to adjust or improve their regimen. Maybe that’s just adjusting their insulin doses, or it might be an opportunity to have the conversation of, “Hey, have you ever discussed with your provider about starting Ozempic or Manjaro?” The patients might not have an outpatient endocrinologist; on the outside, they maybe only have a primary care doctor who possibly is not as well versed or as comfortable prescribing such medications. So it is an opportunity to have shared decision-making and identify strategies to set people up for success.
Then the other thing that I find really exciting in terms of my position as an inpatient or hospital endocrinologist, sometimes we call it an endocrine hospitalist, is to also have a conversation about checking blood sugars. Of course, classically, we use finger sticks, which are painful for some people. They also only give us a brief snapshot of what their blood sugar is doing at that point in time without giving us more robust information about what’s going on in between those finger sticks. Continuous glucose monitors (CGMs) have now become much more popular and are much more visible amongst our population of people with diabetes. So, I’ve become a very strong advocate of starting people on CGMs on discharge. Particularly for those who might be going home on insulin or who have a history of diabetes emergencies, whether it’s hypoglycemia or severe hyperglycemia. It helps people understand how their decisions, how their diet, may affect their sugar levels as well as how to set alarms to keep them out of trouble.
With all of these, whether it’s medications or discussing sugar monitoring, I feel like there is a wonderful opportunity. We frequently, in one of those two regards, do make some tweaks or changes to help optimize them for the rest of their life. Hopefully, unfortunately, it’s sad; I don’t have to see people again. But at the same time, I’m happy when I don’t have to see people again, because that means that they’re doing great.
RK: That’s right. As much as you enjoy seeing people in the hospital, it’s nice when they aren’t required to come back to the hospital. So that is interesting to hear, that about half of people with diabetes in your experience who come into the hospital, maybe were well managed on pills, and temporarily are put on insulin in the hospital, might go home on the same regimen of pills after discharge. But then the other half really might either need to stay on a new insulin regimen or might need some tweaks to their existing regimen on discharge. So again, highlighting the importance of reevaluating what the diabetes regimen is at home and what’s ideal once someone goes back home from the hospital.
You mentioned putting people on continuous glucose monitors when appropriate, and I do think that highlights another aspect of what occurs in the hospital, which is education. Could you talk about who does the diabetes education in the hospital and the role, not only of the nursing staff, but also when someone with diabetes requires a diabetes consultant or an endocrine consultant in the hospital?
AD: Great question. So, education can occur with many different staff members: it can be the bedside nurse; there could be a certified diabetes education care specialist, who I would call a diabetes educator; it could be the hospitalist; it could be the endocrine consultant, as you alluded to, Rita. Any of those people are able to provide diabetes education, and it of course depends on the hospital resources: Do they even have an inpatient endocrinologist or an endocrine hospitalist? Do they even have a diabetes educator on staff? It’s not universal for all hospitals. At the hospital where I work, which is the Johns Hopkins Howard County Medical Center, we are blessed to have a diabetes educator on staff. People who come in with either poorly controlled diabetes or having significant changes to their diabetes regimen, such as starting insulin on discharge or starting a continuous glucose monitor on discharge, we usually do have the diabetes educator come and consult on the patients, and frequently I or someone from my endocrine hospitalist team consults on those people.
I am such a firm believer in education because knowledge is power, and what we want to do is empower our patients to feel comfortable and confident that they can manage their diabetes on their own once they leave the hospital. If they are not comfortable in managing their diabetes, then I feel almost to some effect that we haven’t fully set them up for success.
To answer your second question, at what threshold does a patient with diabetes require an inpatient endocrine consultation? Meaning, at what point should an endocrine specialist come and see you while you’re in the hospital? Again, that does speak to the specific hospital resources that are there. Some rural settings might not have an endocrinologist, or the endocrinologist in town might not be able to make hospital calls because that physician is working in the clinic all day. But in hospitals, for example, large academic centers or hospitals that are employing an endocrine hospitalist or an inpatient diabetes team, we do set some soft thresholds. Now, these are not set guidelines or set in stone, but I would think that people who present with diabetes emergencies like diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state or severe hypoglycemia should be seen by an endocrine specialist. Anybody with an insulin pump and most people with type 1 diabetes, since we know that they tend to have greater sensitivity and more fluctuation in their glucose levels and insulin requirements, would really benefit from having a specialist touch base with them. Pregnant women who have diabetes and are being managed with insulin should have a specialist touch base with them. People who otherwise might be coming in for a hospitalization that is directly related to uncontrolled diabetes, such as an A1C greater than 9 or 10%, and they’re coming in with either a foot infection, a heart attack, or a stroke, at which point you really want a specialist to help assess the individual and truly optimize their medication regimen. Not only, again, for what’s going on in the hospital, but more importantly, for when they leave, so that they don’t have a recurrence of their complication, so that you set them up for success and for health.
RK: Yes, those complicated cases sometimes can take some time to think through the regimen and to follow how people respond to the regimen in the hospital. Having a diabetes management service in the hospitals, where they’re offered, hopefully in an increasing number of hospitals—it is so great that the hospital where you work at can benefit from your expertise—is so important so that we can ensure that management of people with diabetes is ideal and to reduce potential complications as well.
We talked about education; what about diet? If you could talk a little bit about what kind of diet people with diabetes can expect when they’re admitted into the hospital and the role of nutritionists. When might they be consulted during a hospital stay?
AD: Nutrition is so important to our health in any setting, both at home as well as in the hospital. I tell my patients, “You truly, you are what you eat. Every cell, every muscle, every brain cell, skin, bone, is truly constructed of the food that you have put into your mouth, digested, and those building blocks literally become you. So that hamburger, or that salmon, or, that juice that you’re about to consume, that’s future you.” And, as I say, “If you want to have, build an excellent car, a Ferrari, or a beautiful mansion, the Roman Coliseum, you need excellent building blocks to achieve that. If you’re going to put bad quality parts into a car or into a building, you’re going to have a crummy car or a crummy building, that’s weak.”
So, the same truly goes for people, so in the hospital, typically people with diabetes are put on a diet that limits the amount of carbohydrates that they can eat. Now the name might vary from hospital; it might be called a diabetes diet, it might be called a carbohydrate-controlled diet, which is what we call it here at Johns Hopkins. It limits the amount of carbohydrates that someone can eat because a carbohydrate is effectively a type of sugar, and that will potentially raise someone’s glucose in their bloodstream. But also, sometimes people may have other diets included or restrictions depending on their disease. So, if they came in with heart failure, they might be put on a low-salt diet. Additionally, someone who has renal failure on dialysis might have additional restrictions, what we call a renal diet. So, it varies from person to person, but in general, most people with diabetes are put on a carbohydrate-controlled diet.
We find that it is important because even though people might have had conversations with other physicians saying, “Why don’t you just let them eat what they eat at home? Then you can find out what their insulin requirements are. Why are you putting them on a restrictive carb control diet in the hospital?” I respond to that with two reasons:
One, they’re in the hospital for a reason, and we want to set them up for success. We want to give them the best chance to fight the infection, to recover from a stroke or a heart attack, to have their kidneys recover, for example. So, I would be failing as a physician if I didn’t give them the best diet and nutritional status to help them achieve those goals.
Two, I really feel that the hospital is a beautiful opportunity for education and modeling of behavior. So, if we show them, I don’t admonish, I don’t finger wag, and I don’t shame, because that is not the way to educate people and to put them in the right headspace to retain and obtain information. Instead, I like to sit down and say, “What happened, happened, and what you’ve done at home, you’ve done at home. That’s okay. That’s how you grew up, or that’s how you’re educated, or those are just the decisions that you made. But we’re here, right here and now, and we have to look forward to the future rather than backward. So how can we set you up for success going forward in the future? And these are the dietary strategies that are going to afford you the best opportunity to get better, to clear that infection, to improve your A1C, or to improve your vascular disease.”
So that’s why, for me, I think it’s very important to give them those opportunities and to set them up to model the way that what an ideal diet should be and what better place to learn than in the hospital when you have staff that can also continue to reinforce that, like a diabetes educator, a bedside nurse, or the nutrition team. And to your point, when should a nutritionist come in and speak with an individual? I do feel strongly that, again, education is so important; knowledge is power. So oftentimes we do consult a nutritionist, or otherwise called a registered dietitian, which is the official term, to come and speak with a patient who has poorly controlled diabetes or may benefit from diabetes education. They may even have great, well-controlled diabetes, but as I interact with the individual, I might notice that they were never taught even basic dietary strategies or decision-making on how to eat healthy.
Going into a supermarket and trying to pick healthy food and cook healthy meals for someone who was never taught how to do that can be very overwhelming and scary. For me, all of us are different, but things that you’re not familiar with can be scary. If you ask me how to fix a car right now, I know how to change a tire, but that’s about it. Besides that, I would be truly terrified. We must not take for granted the things that we know and then impose them on our patients; they might not know it, and they might be afraid to even admit that they don’t know. It’s always important to have open conversations and then provide them with the resources necessary, both in the hospital setting as well as hopefully setting themselves up for resources to continue to follow up with once they leave the hospital.
RK: I agree, I think that registered dietitians, and diabetes educators, are such tremendous resources really for people with diabetes in the hospital. To have the opportunity to take advantage of that knowledge that they can provide, not only in the hospital, but to carry it over to when you go home is really critical. For those people who can really benefit from that additional expertise and knowledge, it can be critical to have them come by while in the hospital. You mentioned what we call the carbohydrate-controlled diet or a diet where we monitor a certain level of carbohydrates in each meal. There are also alternative nutritional regimens that I wondered if you could talk about just briefly, such as total parenteral nutrition, peripheral parenteral nutrition, maybe just briefly define what those are and when they might be used and how it might impact diabetes management.
AD: In situations where we feel that people are unable to eat food safely or in sufficient quantities that meet the needs of their body, and we know that typically people need roughly, depending on their body size, between 1500 to 2000 calories a day. For one reason or another, either if they’re intubated and unconscious or unable to swallow, if they’re unable to intake that sufficient number of calories to meet the needs of their body, then we have alternative methods to feed people. One method is called tube feeding, and that’s usually accomplished through a tube. Either people have what’s called a gastric tube or a peg tube, or they have just temporarily what we call a nasogastric tube, just the tube that’s in the nose and then goes down into the stomach but can be pulled out easily once they’re ready to actually eat food. Usually then they get almost the equivalent of a milkshake, which is continually poured through the tube to provide them nutrition, we call that tube feeding.
Then there’s peripheral parenteral nutrition (PPN), and total parenteral nutrition (TPN), which literally means food through the IV, through the vein. So we see that there’s usually, if it’s just PPN is typically a large, clear bag that has sugars and proteins in the form of amino acids and vitamins in them. Then sometimes we also have a bag of liquid fat because fat is very important as an energy source and as a building block for our bodies. Typically going through another IV into our veins because that’s continuous nutrition going in, non-stop, typically throughout the whole day, or even if it’s just going through 12 hours, for example. But it’s a continuous infusion rather than naturally What we do is we just have a meal and then we go hours without a meal and then we have another meal and then go hours without. That’s how our bodies are meant to be eating, and that’s how you evolved to be.
So to have continuous nutrition typically means a nuance and adjustment in terms of our insulin decision-making. Usually people are put on short-acting insulin every 4 hours to compensate for the continual glucose and energy that’s coming into their body through either the veins or through a continuous tube feed.
RK: Sometimes, especially for people who are on these different regimens, either through the tube feeds or through the veins, as you mentioned, just understanding that it might require a different type of insulin regimen. We haven’t really talked specifically about the kinds of insulin regimens that people may be on in the hospital, and this might be a good juncture to do that. We mentioned that most people, if not all people, will need, on a temporary basis, no matter what they were on before the hospitalization, to be on insulin during their stay. But what kinds of regimens might those look like? You mentioned if someone is on continuous nutrition, they are getting insulin injections every 4 hours, or what we call standing doses that they get. But for someone, let’s say that was on just metformin or just a few pills at home, what might their insulin regimen look like while in the hospital?
AD: Diabetes management in the hospital setting is very nuanced. For people who have, I would consider colloquially, very mild diabetes, so their diabetes is well controlled just on diet alone or maybe just on one pill alone, they might be able to get away with what we just call correctional insulin or sliding scale insulin and nothing else. Just see for 24 hours what their sugar levels are doing, and only if the blood sugar is starting to go high do you get a little dose of correctional insulin to help try to bring it back down to normal.
But for patients who are either taking insulin at home or who are taking multiple pills of diabetes medications at home or who come in and their diabetes is uncontrolled, meaning that their A1C typically is higher, above 9%, for example. Those people, we need to start them right off the bat on what we call basal-bolus insulin. And what does that mean? What is basal insulin? What is bolus insulin?
So, I like to use analogies because I think a picture is worth a thousand words. I like to use the analogy for my patients that our bodies are like a car. On a cold winter day, you don’t want to just jump into a cold car. Let me use my remote start, and I’ll start the car, but I’m not actually going to drive it, I’m going to let it sit there and just warm up. It’s going to be using the same amount, basal amount of gasoline. If I just let it sit in the parking lot for the whole 24 hours, it would continually use the same amount of gasoline, all day long just to maintain the very basic organ functions of the car. Similarly, our body is the same way; if we were just sleeping or resting or not doing anything all day long, we still need a basic amount of glucose to enter our cells as fuel to fuel our heart and our lungs and our kidneys and our liver.
So, you just need a basal amount of insulin to allow the glucose to actually go into the cells because insulin effectively acts as a key to open the door and allow the glucose molecules to go into the cells. Because you just need that same base amount, there’s actually what we call basal insulin. A common one used in the hospital is glargine. They’re typically once-a-day insulin; they just have a flat rate of action. It is just using the same amount of activity the whole 24 hours, and that’s why you’ll need to inject it once a day. It helps compensate just for basic metabolic needs while resting.
Then, on top of that, we have what’s called a bolus, or rapid-acting insulin. That is very fast acting, because the car, suddenly, you’re ready to go into drive, and you’re ready to start driving to work, or to the supermarket, or to your kid’s soccer game. The gasoline requirements, when you put it into drive, shoot up quickly until you hit a red light and then back to your basal. Similarly, in our bodies, when we eat food, the amount of glucose that’s now all of a sudden coursing through our bloodstream spikes up quickly. The insulin requirements to compensate for that glucose spike also need to spike up quickly, but they don’t need to stay spiked up for 12 or 24 hours because we metabolize the glucose that we’ve eaten rather quickly.
That’s why we eat breakfast at 8 am, and then I’m hungry again at 12 pm, just 4 hours later. Then usually around 3 or 4 pm, you need that mid-afternoon snack. Usually we eat dinner around 6 or 7 pm for most people. Around every 3 or 4 hours we finish metabolizing the nutrition from our food, and we’re ready to eat a new meal. For that reason, scientists have invented rapid-acting insulin that typically lasts only 3 or 4 hours to compensate for that rapid short glucose surge. In the hospital you would typically get one shot of basal insulin a day and then a shot of what we call bolus or rapid-acting insulin with each meal.
Then on top of that same rapid acting insulin, also you might get a couple extra units based on what we call, again, we’ve talked about this correction or sliding scale. Because if you had a hamburger and your blood sugar is 120 mg/dL, you might only need five units, the nutritional dose to compensate. Five units is just a pure example, it could be ten, could be fifteen, depending on the person. But you just need, let’s just say five units to compensate for the nutrition of the person. Hamburger buns that are going into your, eventually into your bloodstream. But if your blood sugar is 220 or 320 mg/dL, that’s much different at that point in time, that you’re eating that hamburger, than if you’re eating the hamburger at 120 mg/dL. So the person eating the hamburger at 320 mg/dL of course needs extra insulin or correctional insulin to help both compensate for the nutrition going in but as well as to correct them to bring them back down to 120 mg/dL hopefully by lunch or dinnertime.
RK: I loved that analogy about metabolism and why we need these different durations of insulin and different frequencies of insulin as well.
There’s also the insulin drip, giving insulin through the IV that some patients may need even further. I wonder if you could talk about what that is and why and when it might be needed.
AD: The insulin infusion, or the insulin drip, as we like to call it, is something that is typically done only in certain situations. A classic situation is diabetes emergencies, such as DKA or hyperosmolar hyperglycemic state. A lot of time people with diabetes or any type of hyperglycemia in the intensive care setting might be put on an insulin drip to help regulate their blood sugars. In these situations, the insulin infusion or the insulin drip is not only really, in some regards, more potent or more powerful than the injection because it goes straight into the bloodstream rather than the injections that go into the adipose tissue (the fat) and they need to be slowly absorbed from the fat into the bloodstream. It also allows us to make quick adjustments or stop the insulin entirely on a moment’s notice, whereas we’re not given that capability with an injection. Once you inject the basal insulin, that basal insulin is sitting there for 24 hours, whether you like it or not. Even the rapid-acting will be sitting there for 4 hours, whether we like it or not.
Whereas with an insulin infusion, you can change the dose—technically we can change it minute to minute—but most of the time we make adjustments every hour, as necessary, to help keep a blood sugar within the target range, which is typically between 100 and 180 mg/dL. Other instances where we might use an insulin infusion are after certain surgeries, such as cardiac transplant, pancreatectomy, or pancreas transplant, as well as with mothers who might have type one diabetes who are actively in labor. In all of these situations, for these specific and high-risk individuals, it affords us the best opportunity to have maximal glycemic control.
The question is, so then why don’t we do it on every person with diabetes? Because it’s very labor intensive, and typically the types of people that are on an insulin infusion need to be in a special monitored setting, such as an intensive care unit with typically one-to-one nursing, because the blood sugar can change rapidly when you’re on an insulin infusion.
RK: I think that is an important aspect to keep in mind, that the degree and frequency of insulin given and really the route by which it’s given, whether it’s an injection or an infusion through the veins, depend on what the medical reasons are for the admission and what the short- and long-term goals are. Understanding that someone can bounce back from being on an infusion to going into the injections, or maybe the other way, going from the injections to an infusion. This depends on whether their clinical condition is improving or worsening. It is great to have this flexibility, to be able to give insulin and meet the needs of the person in the hospital that might change throughout hospitalization too.
One of the hot topics that is out there is having to hold certain diabetes medications before procedures and before elective hospitalizations or when you know that you have to be hospitalized for whatever reason. Could you talk a little bit about that? What medications might require a little extra attention before a planned surgery? For instance, if you’re getting cataract surgery, would you have to hold medications such as GLP-1 receptor agonists or SGLT2 inhibitors beforehand, or even metformin? How far in advance do people need to hold these medications before being admitted to the hospital or undergoing a procedure?
AD: I will preface that anything that you hear here must first be discussed with your physician, as everybody is different in everybody’s situation. In general, people who are undergoing anesthesia—they will ask that the long-acting, once-weekly GLP-1 receptor agonists be held for at least a week prior to the procedure. They are known to slow down gastric emptying, and therefore they might have a greater risk of having food still left in the stomach, even from the day before. In the unlikely but unfortunate scenario that somebody vomits food, they can actually aspirate and go into their lungs, which actually can lead to a very dangerous situation. For that reason, most centers now request that people not take their long-acting, once-weekly medicines at least a week prior to a procedure. The daily versions, such as liraglutide (Victoza) or the oral medication semaglutide (RYBELSUS), typically right now they are still recommending that you can take it up until the day before the procedure and just hold it on the morning of the procedure. There is a lot of research; it is a very hot area of research, and so I’m sure we are going to be having changes of recommendations in the next year or two, so watch this space.
There’s another wonderful class of medication that I truly love called the sodium-glucose cotransporter-2 (SGLT2) inhibitors. So for our patients listening, basically the two most common ones are Jardiance and Farxiga; there’s also Invokana, Steglatro, and Brenzavvy, and this class of medications is also wonderful because they help protect the heart, they help protect the kidney, but rarely they can predispose people to going into a diabetic emergency, ketoacidosis. That’s why the FDA has really recommended that for people undergoing surgery, that really should be held for at least 3 to 4 days prior to undergoing surgery. Now, for something like a very simple cataract surgery, in which their diet is not actually affected, one could argue that it’s not as important to hold the SGLT2 inhibitors because they’re going to be eating as they normally do right after this very rapid procedure.
For larger surgeries or procedures that involve the gut in which people might not be eating normally; for example, colonoscopies in which you have to do a bowel preparation, and you have to take medications to clean out your stomach, and so you’re not eating as you normally would. In those situations, and in larger surgeries, I recommend that you withhold your SGLT2 inhibitors like your Jardiance or your Farxiga at least 3 to 4 days prior to even preparing for the surgery. Other medications, typically we say metformin or the sulfonylureas like glipizide or glimepiride, or the Dipeptidyl peptidase-4 (DPP-4) inhibitors like Januvia or Onglyza—all of those medications—we typically say to hold on the morning of the procedure, but you can still take them the day prior to the procedure. Lastly, insulin is very tricky, because it can depend on the type of insulin that you’re using and what time your procedure is taking place. And are you a type 1 or a type 2 individual? But in general, with insulin specifically, it’s very important to talk with your provider for your specific recommendation. In general, we say that you can take your medication the night before as you normally would, but on the morning of the procedure, you might need to decrease the doses of your basal insulin down to either 80% or even 50% of your home dose. You should not take any rapid-acting insulin if you are not eating. You should only restart the rapid-acting insulin after you have started eating.
RK: Those are all really important general recommendations to keep in mind. As you highlighted, really talking to your health care provider—asking which medications might need to be held and for how long, and practices for withholding or reducing insulin, even the night before in some cases, but definitely the morning of—shows that it is very important to talk to your health care provider.
Then there might be reasons that you’re admitted to the hospital; they’re unplanned for, and you can’t do this ahead of time. But for those where you know you are having a procedure, or you know that you have what we call an elective admission, where you have to be hospitalized for one reason or another, these are all really good tips to keep in mind.
It is also important, as you mentioned, to talk to the health care provider, your clinician, on the outpatient side about when to resume medication again. It could be that you might have to wait to start them again after discharge. Talking about discharge planning now, at the end of the hospitalization, when someone’s ready to go home, what are some of the aspects that a patient should expect to receive in terms of details from their health care team? What kind of questions should they ask? For instance, when should they call their health care provider, and for what glucose number? Then how does communication work with the outpatient diabetes provider?
AD: I think that the discharge process is actually, potentially, the most important part of what we call inpatient diabetes management. Unfortunately, oftentimes, it is overlooked or is just a second thought to some of the other inpatient diabetes management issues that we encounter. Truly I cannot emphasize enough that it is so important to set people up for success because hopefully they’re living outside of the hospital 99% of their life and only in the hospital 1% of their life. So we really need to make sure that 99% is optimized to ensure continued health.
I like to say that there are at least 3 pillars to set people up for a successful discharge. One is, as we’ve alluded to, medications. Having the discussion, “Does the home medication regimen need to be adjusted?” If it is being adjusted, “Are the medications affordable?” Because there is nothing worse than sending somebody home on, “I think this is going to be the perfect regimen for you. You should be on Ozempic and Jardiance and insulin,” and they go to the pharmacy, and they have a second heart attack because the cost of the medications could be $2,000 or more; Ozempic alone out of pocket is $1,000 a month. If your insurance doesn’t cover it, it becomes unaffordable, and you’re setting them up for failure. It’s important for the medical team to confirm that any medication changes are actually covered by the insurance and are affordable for the patient.
Secondly, as we alluded to, is checking sugar. How are we going to know that we’re achieving success once we’ve left the hospital? Is it going to be using finger sticks? Or will it be using a continuous glucose monitor? Again, that’s a conversation between the clinician and the patient, considering the patient’s preferences, cognitive abilities, as well as dexterity and cost. Of course, as you’ve heard prior, my bias is I’d love to put people in CGMs or continuous glucose monitors when I can. At the end of the day, again, that conversation has to take place of, “Is it affordable for you? And do you even know how to put it on?” I can say you should do it, but if people don’t understand how to actually put on a CGM and how to pair it with their smartphone—does the app even exist on their smartphone? Because not all smartphones have a compatible app that can then pair with every CGM. Sometimes people must get a separate standalone reader, and it really depends, and that conversation is important.
On discharge, the threshold that a patient is ready is that they feel comfortable and confident in their ability to manage their diabetes at home once they leave. Now they might not be 100% comfortable, as someone is starting to learn Spanish or starting to learn how to ride a bike. You might not be 100% comfortable doing it, but at the very least you have the basic know-how of what’s necessary. So if you’re going to be going home on insulin, someone should have taught you how to take insulin. Either a bedside nurse or diabetes educator should have shown you, with an insulin pen, how to put on the pen needle tip, how to dispose of it, and how to inject it. These are very important details that, again, clinicians or healthcare teams might take for granted, but if a patient has never done it before, it’s foreign to them. Modeling and the teach-back method, to show that the patient truly knows what they’re doing is important.
Every patient on discharge should be given a printout sheet that contains a list of their new medications and doses, follow-up appointments, as well as thresholds on which to go back or thresholds for which to notify their physician or to seek medical attention. I put that in all of my discharges for all the patients that I see; common thresholds might be “recurrent hypoglycemia: blood sugar less than 70, changes in symptoms,” or also “severe hyperglycemia: blood sugars that are above 350 and that are unable to come down with the medications that you’ve been prescribed.” In those situations, I think that people should be at least calling their provider or seeking medical attention, and that should be spelled out on their discharge summary.
RK: I think those 3 pillars are so important. Especially, making sure that they’re all covered during a discharge discussion with the healthcare team. Patients should certainly feel comfortable asking questions during that discharge time, as you mentioned, because the goal is not to just go home and figure everything out on your own, but really to have continued support and a plan of care.
AD: People, in order to really achieve success, need continued education and continued follow-up. Once you leave the hospital, how do we make sure that you’re not lost in the shuffle, that you don’t fall through the cracks, but rather that you have continued guidance in your journey with diabetes? I don’t expect somebody to be proficient with the language of diabetes after just one or two educational sessions in the hospital. In my mind, that can mean setting them up with a diabetes self-management training program or other outpatient diabetes education courses. I know here in Howard County we have the Living with Diabetes class to set them up, maybe potentially with a registered dietitian appointment on discharge.
Then really most importantly, is making sure that they actually have a primary care physician appointment, if appropriate, a referral to an outpatient endocrinologist to follow up with them. Usually, again, the same threshold applies for inpatient endocrine consultation as when I refer people to an outpatient endocrinologist, and that they either came in with a diabetes emergency or have poorly controlled diabetes or might be started on insulin and would really benefit from closer follow up with more care with regards to their diabetes.
RK: That’s all been such great information that you’ve gone over. It is so important for our listeners to know that if you do have to be admitted to the hospital, for whatever reason, that you will be taken good care of and that the regimens might temporarily change. Most importantly, on discharge, you might have some tweaks to your regimen. Knowing what the follow-up is and having a good plan of care is critical. Hopefully, with this knowledge, people will feel more comfortable should they have to be hospitalized and also know that it can be a smooth process as well, just even having the basic information.
Are there any last words that you wanted to share with our listeners if they do find themselves in the hospital at some point in the future?
AD: Don’t feel shy to ask questions, and you have to be your own best advocate. If something either doesn’t sound right or something is just confusing, there’s nothing wrong with asking and getting a better understanding of why something’s happening or what should be done. Ultimately, you are the most important person in the room.
RK: I wholeheartedly agree, and thank you so much, Dr. Demidowich, for your expertise, your education, the great analogies, and really walking through this entire process from precautions before being put in the hospital to what happens in the hospital and then what the transition should be back to home. We really appreciate all the knowledge you shared today. So thank you so much.
AD: Thank you, Rita, for having me. It was an absolute pleasure.
RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit hopkinsdiabetesinfo.org.
We love to hear from our listeners. The email address is hopkinsdiabetesinfo@jhmi.edu.
Thanks for listening. Be well and see you next time.
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- Home - | - Episode 38: Dental Health and DiabetesIn Episode 38, Dr. Kalyani welcomes Karl Zeren, DDS. Dr. Zeren was raised in Towson, Maryland and completed a Bachelor of Science degree in Psychology at the University of Maryland at College Park. He attended the University of Maryland School of Dentistry and finished his Dental training in 1975. He was on active duty in the United States Navy for 2 years finishing a general practice Residency at the Naval Hospital in New Orleans, Louisiana. He returned to Baltimore to study Periodontics at University of Maryland under the world-renowned Periodontist, Dr. Gerald M. Bowers, completing his Residency in 1979. He opened a practice limited to Periodontics in the Timonium area and has been actively involved in both private clinical practice and dental education since that time. Dr. Zeren began teaching in the Residency Program at the University of Maryland in 1980. Dr. Zeren became Board Certified in Periodontics in 1986 and has continued to pursue and develop important advances in clinical science and technology to enhance his patient’s treatment outcomes. Currently, Dr. Zeren assistant clinical professor of Periodontics and Periodontal Implant Prosthetics residency program at University of Maryland School of Dentistry. He is involved with treating residents in the multidisciplinary fields of Periodontics, Periodontal and Implant surgery and implant prosthetics.
DOWNLOAD TRANSCRIPTEPISODE 38: Dental Health and DiabetesDr. Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani at Johns Hopkins. We developed this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.
Today, we are pleased towelcome Dr. Karl Zeren, who will be educating us on diabetes and periodontal disease. Dr. Zeren received undergraduate and dental training from the University of Maryland. He served on active duty in the U. S. Navy at the Navy Hospital in New Orleans, Louisiana, and completed postdoctoral training in periodontics at the University of Maryland in 1979. He’s a former assistant clinical professor of periodontics in the periodontal and periodontal implant prosthetics residency program at the University of Maryland School of Dentistry and retired as a Clinical Associate in the Department of Otolaryngology at the Johns Hopkins University School of Medicine.
He has lectured extensively on guided bone regeneration, implant surgery, implant aesthetics, and 3D imaging, both nationally and internationally. He currently works in private practice, West Perio, in Maryland. Welcome Dr. Zeren.
Dr. Karl Zeren, DDS : Thank you very much, Rita. I appreciate the opportunity to speak with you and share some information.
RK: We are excited, Dr. Zeren, to have you here on the podcast today and to learn about this important issue and condition that can affect people and particularly people with diabetes. I wonder if you could start off by telling us:What is periodontal disease? What are some common signs and symptoms that individuals should be aware of?
KZ: Rita, it’s really interesting because it’s one of the most common, if not the most common disease known to man. It’s there. It is in fact an inflammatory disease, and it’s triggered by the natural germ population that occupies the oral cavity. The oral cavity is typically going to harbor about 100 plus billion bacteria at any one point in time, which is normal. The bacterial population creates a film – it’s a biofilm – and it’s important that people understand that bacteria in their mouth is not necessarily bad – it’s essential.
We live in a sea of bacteria and viruses; mother nature has given this film as a source of protection. The real issue is when this germ film has a chance to over accumulate on the tooth surface. The tooth surface has a little bit of electrostatic charge on it that allows the germ film to adhere. When that starts to overgrow, particularly right around the gum line, it’s going to trigger inflammation. That’s called gingivitis. As long as the inflammation resides solely in the soft tissue, then it’s a reversible process. The problem is that when it’s allowed to continue. It can extend down into the supporting structures, down into the ligaments that holds the tooth into the bone, and the bone itself. That’s when the problems really start, and the issue is, early on, it doesn’t hurt. And many patients will say, “Dr. Zeren, it doesn’t hurt, why should I worry about it?” Obviously, there are an awful lot of medical conditions that don’t hurt until it’s too late. That’s realistically what we get down to. Early diagnosis of this problem is important. Patients should be aware that if their gums become red and swollen and bleed, this can really be a problem. And as this disease progresses, the teeth can get loose and literally fall out.
RK: Wow. That’s interesting. It sounds pretty complex when you break it down in that way. Just to reiterate some of the things you said, it sounds like bacteria is normal in the oral cavity, the mouth, the esophagus. It sounds like it’s needed to digest food. Is that right? And what we’re talking about is when there’s an abnormal growth or an overgrowth in parts of the mouth and other parts of the oral cavity where it shouldn’t be, such as the bones and the teeth and where it can really cause problems. But what about the gums? I think part of what confuses me sometimes is the distinction between gingivitis or inflammation of the gums and periodontal disease. Are they the same or are they different?
KZ: Periodontal disease is the overreaching disease, just like diabetes is the overreaching and you break that down into multiple subcategories. Periodontal disease incorporates gingivitis periodontitis. Again, gingivitis is inflammation of the gum tissue itself. If the bacterial challenge is sufficient, then it can break down the natural seal between the tooth and gum. There’s a relationship between tooth and gum, somewhat like that between fingernail and cuticle. When the bacterial challenge occurs you have to, first of all, have a susceptible host. But, when that occurs, it’s going to get into those underlying tissues and start to destroy those tissues. But having said that, I think it’s important to understand that about 53 percent of the population is not genetically prone to bone loss, although they can have significant inflammation in the tissues, the tooth decay and things of that nature, you’re not going to lose bone. This really gets down to how they’re immunologically programmed. In about 47 percent of the population, you’re going to see a broad spectrum of vulnerability. Everybody has a large germ population in their mouths. But that does not necessarily mean that person’s going to lose bone, and that’s important. So, there’s this whole genetic component to this as well.
It’s a very common disease. And I think that when we start to look at the impact, based on some of the research I’ve done, about 38 million people of all ages in the United States have diabetes. And again, it’s a very common problem as you well know.
RK: I think it’s potentially one that most people don’t pay attention to in terms of you have the bacteria in your mouth. You have this germ film, like you talked about, but it sounds like when there’s an overgrowth, when there’s too much of that, and in those people who are particularly susceptible, such as those who have genetic factors, like you said, or perhaps other conditions such as diabetes, as we’ll talk about, that they might be more at risk for the complications, particularly the bone complications in the teeth. What causes this overgrowth? And perhaps that’s the million dollar question. But, why does it happen that some people might have overgrowth of this natural germ fill in their mouth and the old cavity that puts them at risk for these periodontal complications?
KZ: As I said earlier, we’re all going to harbor this germ population. The real issue is whether the individual understands what they need to do to control this germ film and, in fact, does it. We know that we can educate patients, advise them, and things of that nature, but they also have to get on board with their own personal care. In patients who are genetically prone to periodontal infection, or bone loss. If they’re adequately treated, if they’re brushing effectively, flossing effectively, using antiseptic mouth rinses, [that] can slow down the rate at which the germ film can reorganize. Then they can get into a maintainable state. But this germ film is constantly growing and that’s really the issue. And it requires daily management.
RK: It certainly sounds like this is something that needs to be maintained and given attention to on a regular, if not daily basis.Turning to people with diabetes, if we could just talk a little bit about the risk in people with diabetes. Do people with diabetes have a higher risk of gum or periodontal disease and how high really is that? Is it higher in people with uncontrolled blood sugars [or] on particular medications? What do you usually tell your patients?
KZ: There’s no doubt that diabetes is going to impact periodontal disease. There’s a very clear relationship between a patient, their glucose level, or hyperglycemia, and the degree of inflammation that we see in the oral cavity. Research clearly shows that in that population, when you control the germ film effectively, then the patient’s glycemic control improves markedly.
There’s a very definite correlation between the two of them. When you have this increased glycemia, as you certainly appreciate.It’s going to reduce blood flow in vessels and things of that nature. It’s going to begin to alter how the immune system is able to function. It weakens the immune system and patients that have periodontitis they are threefold greater risk in patients that have diabetes. There are really significant issues that go into that. But ultimately there is a very significant relationship between the two and just management’s important.
RK: That’s interesting to hear the bidirectionality, that it can go both ways. From what I understand, from what you said, that people with diabetes can be at higher risk of developing these periodontal, these gum conditions. But also by managing effectively the dental health, the periodontal health and preventing this from happening, it could contribute to improved diabetes management. Is that right?
KZ: [It] absolutely does, and research clearly shows that there’s a direct correlation – one to the other. We understand that if there’s hyperglycemia, there’s going to be a lot more glucose in the saliva. That opens the door for the bacterial populations to be even more overgrown. So, you create a better micro-nutritional base for this bacteria. We then realized that from an immunologic point of view, the system is just not as competent. From a vascular point of view, you’re not going to get the same blood flow. You’re just creating this perfect storm.
RK: It certainly does sound like it can be a vicious cycle that really needs to be broken in order to effectively manage not only the periodontal conditions, but also to manage the diabetes as well. What about diet? Do you think that what we eat can impact our risk of periodontal disease? And do you think this has bearing on people with diabetes in terms of what we should recommend for food?
KZ: Obviously a patient who’s diabetic needs to really be aware of their carbohydrate intake. And when we look most immediately in the oral cavity, if people are snacking on really dense carbohydrates, they tend to help accumulate on the tooth structure which opens the door for even more issues.
A healthy diet, people look at that’s rich with fruits and vegetables, very important all the way around. I think that diet probably is going to impact diabetes more than the oral cavity as long as there’s not a lot, again, carbohydrates, sugars don’t help out a lot. But no, interestingly people will say, “If I eat a candy bar, do I have to go brush my teeth?” and the answer is – “No.” You’ve got to control the germ film, and the germ film is constantly cycling. If you have adequate hygiene and you’re performing that effectively on a daily basis, then the germ film’s not really given the opportunity to significantly overgrow and start this whole process.
But it is the day-to-day effective hygiene that’s important. And oftentimes, in my experience, I’ve been in practice for over 40 years, patients oftentimes, do not know:
- That they’ve got a problem.
- Really how to manage it.
I’ll ask people, “who taught you to brush your teeth?”- “I guess my mom did, or my dad,” or this or that. And they’ll observe a behavior and carry it out, and assuming, because they’re performing the behavior, it’s effective. And oftentimes, it’s flatly not. Okay. Being in the hands of a really good dental professional who’s looking at how effective you are with your day to day hygiene is really essential.
And coupled with that, is how to identify that subset of the population. Again, coming back to the fact that 53 percent of the population is really not at risk to lose bone. But it’s in that other 47%. And those are the people that really need to be educated more and more about these kinds of things.
Diet being one thing, but smoking is terrible when it comes to dealing with periodontal problems. We look at an increased risk of disease not being two or three times, but as much as five to 10 times greater risk because of that impact. And if you are diabetic on top of it; you’re in trouble.
RK: It certainly does seem that, as we see with other conditions, such as heart disease, the combination of diabetes and smoking can elevate the risk of these gum and tooth issues. The periodontal disease that you talked about. What are some signs and symptoms that people might be aware of? Or is this largely silent in the early stages? I know we talked briefly about teeth falling out, which seems like a kind of a later stage. But what might be some early signs and symptoms, if at all, that someone with diabetes should be familiar with?
KZ: Again, from an immunologic point of view, their system’s not going to be as competent. It’s not going to be as responsive. Even with a lesser degree of germ overgrowth, we’re likely to see the tissues swelling. We’re likely to see bleeding when they’re brushing their teeth. Those are very early, very solid indicators of a problem. And as you appreciate, there are a lot of people, from my research, about 7 million people, who have diabetes, don’t even know it.
And I’ve certainly seen patients when you track people over a long period of time and stability and all of a sudden that stability is gone. And you ask them, “Have you had a recent physical? Have you talked to your physician about diabetes or anything else going on?”
“No, I don’t want to go do that.” Then you start to see significant bleeding. You start to see abscess formation, purulent, pus, drainage around teeth. That’s a real trigger. And I’ve certainly. referred patients to their physicians and they come back. Yep, you’re diabetic. It’s there.
And for people who are questioning this, certainly if they’re starting to see bleeding when they’re brushing their teeth or flossing, then that means that’s not it. They’re not in control of the situation and they need to seek professional care.
RK: That’s interesting. And it’s true that in some cases, perhaps it’s the dentist or the person who examines your teeth that is the first to detect signs of periodontal disease. And perhaps that could, in some cases, be the first sign of underlying metabolic disease or diabetes. Have you detected individuals in your practice in that way, who didn’t know they had diabetes and the first manifestation or one of the early manifestations was periodontal disease?
KZ: [I] absolutely have. And studies coming out of Columbia indicate that dentists, in a very large majority of the time, helped to identify these early signs and get people on the road to getting these things managed.
So absolutely, it’s important to have that, but what should a patient expect from their dentist at the same time? The world’s getting busier and unfortunately, less time is spent in focused care. Management. They should have a clinical examination that would include probing depths. And if probing depths are normal, then they’re going to range maybe one to three millimeters and there would not be any bleeding. But if the probing depths are going four or five and six millimeters and there’s bleeding, then you have a susceptible host. All right? If the patient’s day-to-day hygiene appears to be adequate. Meaning that you’re not seeing a lot of accumulation of plaque or calculus and you’re still seeing this increased probing depth, then immunologically something else is going on here and that’s when you start to really think about diabetes as a coconspirator in this problem.
RK: Yeah, getting back a little bit to what we were saying about, sometimes diabetes may be detected for the first time in dental practices. It is interesting that in our clinical guidelines, even for diabetes management, there are guidelines talking about that utility of screening for diabetes in different health care settings such as dental practices. Because most people do or should go see their dentist at a recommended frequency per year, and that could sometimes be even more frequent than they see their primary care doctor, unfortunately, in some situations.
For sure, I think any health care provider really being vigilant and on the alert for complications from diabetes, can sometimes be the first to help bring attention to the diagnosis. You mentioned some aspects of the dental examination that might be part of a comprehensive dental exam that someone could experience when they see their dentist.
What are the preventative measures that are usually recommended for people with diabetes, in terms of how often they should be seeing a dentist?
You talked a little bit about what they should expect from their dental exam in terms of probing depth. I wonder if you could. Maybe give some details on what that is.Is that how receded the gums are? And then, how often and how should they be brushing their teeth? I think that’s a big question I hear from my patients often too, and I’d love to hear your thoughts on that.
KZ: Rita, it’s a really important question that you just posed. And in looking at the diabetic patient, the first thing we want to determine is: Are they also genetically prone to periodontitis? And I’ve seen plenty of insulin dependent diabetic patients who have adequate oral hygiene and don’t show any real signs of breaking down. We need to separate out people who are genetically, not prone to periodontitis, and have diabetes versus those patients who are genetically prone to periodontitis and have diabetes. So that’s a really important point to understand.
In terms of what they do, brushing and flossing on a day-to-day basis is essential. Having effective examination, this is really key for people. Making sure that they are getting probing depths, their evaluation of the degree of inflammation that is present from one visit to another is important. So, if we start to see an increased level of inflammatory change from one visit to another, that would suggest that we don’t have stability. In terms of brushing and flossing, using an electric toothbrush is very helpful. I’ll ask patients, again, like we said, “How often do you brush your teeth” and “I brush once a day, I brush twice a day, I brush four times a day.”It’s not much a function of how often you do it- it’s how well you do it. And that’s really an important consideration. Again, “Who taught you to brush your teeth?” Is another key question. People should rely on their dental hygienists to coach them on how to effectively brush and floss. And as long as they’re doing that effectively , underlying that word effective, then they’re controlling the underlying etiology. And the more that we can control that etiology, the less opportunity these other complicating factors have to impact.
RK: So that’s interesting because often people will ask, “Should I brush after every meal? Do I need to bring my toothbrush to work with me?” And from what I’m hearing, clearly it can only help, perhaps, to brush more often, but more importantly, it’s the quality of brushing from what you’re talking about. Is that right?
KZ: Yeah. Interestingly enough, this whole idea of having to brush your teeth after every meal and see a dentist every six months comes from a toothpaste commercial produced in the 1930s. Ipana toothpaste, as a matter of fact. The goal of that commercial was to get people to squirt more toothpaste on a toothbrush and they imply that the food that you eat causes dental disease. It’s important to understand that if you’re brushing effectively, then for the vast majority of people, once in a 24-hour period is sufficient; number one. Number two; the food that you eat in general does not cause dental disease. It’s the germ overgrowth, tooth decay, and periodontal disease that are triggered by that germ overgrowth. And I think that’s really essential. You don’t need to take a toothbrush to work with you. Okay, if you brush in the morning, at nighttime brush and floss at some point. Also very simply understanding that we’ve got this large germ population, if you can rinse with an oral antiseptic, Crest has one, Listerine has one that says antiseptic on it, then if you’re rinsing with that, a couple of times a day for 20 seconds or so, you’re simply slowing down the rate at which that germ film can reorganize itself. These are the very simple things that people can do to help control the environment and its environmental control.
RK: That seems to be such an important point that really, if you are brushing adequately in the morning and evening, doing the antiseptic, doing the flossing, that it sounds like your germ film should be adequately controlled. If you’re doing it optimally throughout the day then you don’t have to brush after every time you eat. Is that right?
KZ: Correct. Yes. And people who brush after every meal tend to cause a lot of gum tissue recession. They’re causing harm to themselves. And typically, if they’re using a manual toothbrush, they go into ritualistic behavior. They start carrying out a behavior and they’re not really thinking about what they’re doing. They assume because they’ve got a toothbrush in their mouth, that it’s controlling the germ film and oftentimes it’s not the case.RK: [It seems] to be another example where too much of one thing may not be a good thing. And it’s important to know how to do the proper technique.
What do you tell your patients about the proper brushing technique? How long should we be brushing at a time? And should we be angling it in a certain way? Should we be covering the teeth in a certain way? Are there some general principles that you could share?
KZ: Absolutely. And obviously this has been, this has evolved over a century of time with different people suggesting that you should angle the brush in one way or another, and you should do X number of strokes and things.
The most effective single thing you can do is to begin using an electric toothbrush. These modern electric toothbrushes have pressure sensors in them, giving you immediate feedback. Some of them in fact have apps that will help you to understand where you did and did not clean effectively. But using an electric toothbrush and allocating 2-3 minutes a day with that brush carefully going around your teeth is exactly what you want to try to accomplish. Often times people will rely on looking in a mirror and assuming that they’re translating an effective activity and it’s not necessarily the case. Interestingly, if a person simply sits down on the bedside or a chair and focuses on where they are in their mouth and what they’re doing with that brush, they’ll tend to be imminently more effective in controlling the germ film.But it’s a new behavior. That’s one of the behaviors that we constantly are coaching people to incorporate and as they do, they all will often remark, “I just can’t believe how much cleaner my mouth feels as a result.” These are very simple things, but we have to break-up old habits that are full of assumption and not effect.
RK: Yeah. That seems like a relatively simple thing to do, to have a mirror as you’re talking about to brush your teeth and but could have profound benefit is what is what I’m hearing. Is that right?
KZ: Absolutely. It’s controlling the etiology. You’re controlling the underlying causes. And as you appreciate, the more effective you are in controlling etiology, more effective you are in helping to maintain health.
RK: For sure, I fully agree. For those listeners who may not have an electric toothbrush, let’s say, for lack of a better word, an old school toothbrush that you don’t plug in. Could you still get adequate dental hygiene that way? Would you have to brush longer? Are there certain kinds of bristles you recommend? What do you usually tell your patients?
KZ: That’s a really important question. Certainly, a manual toothbrush can provide very adequate debridement or disruption of the germ film. You want to use soft bristles. People oftentimes will hold a toothbrush, like a hockey stick or a screwdriver and just whale on themselves, and that’s not really helpful at all. Holding the brush in your fingers and consistently and lightly going over the same areas in a routine fashion is very effective. It’s very effective but certainly steer clear of a hard bristle brush because that can cause a tremendous amount of damage. And again, if the individual has the opportunity to incorporate an effective antiseptic rinse, it’s again, just giving them another layer of control.
RK: And we’re talking about with a soft bristle brush, a light rotating motion, or is there a particular motion you recommend in brushing the teeth?
KZ: [There are] a lot of philosophies on that, but I think an overlapping stroke with gentle pressure and, allowing literally 30 seconds to go from ear to ear on the outside and ear to ear on the inside in each arch. You’re going to end up maybe brushing for two minutes and just do it lightly and in that kind of a stroke, as long as it’s overlapping. That way you’re much more effective in dispersing the germ film. You’re not getting rid of it. You’re simply trying to disperse it.
RK: That’s an interesting point and the overlapping aspect as well. It sounds it could be rotational, it could be angular, it could be back and forth, as long as it’s overlapping. Is that right?
KZ: Yes.
RK: That’s great to know because for some individuals, they might prefer to do it one way or another. It’s good to know that there’s many different ways to achieve the same outcome, which is improved dental health. One of the things we talked about was how often people with diabetes should see their dentist. You made the important distinction between those people with diabetes who might be more genetically prone to have dental disease versus those that are not as high risk. For the general person with diabetes, just the general population; how often should they be seeing their dentist? Clearly those who are at higher risk might go more often.
KZ: Yep. Again we talked about this, commercial suggesting that a person should be seen every six months. That’s again, marketing. If we have a patient who is genetically prone and they’re diabetic, they probably should be seen three or four times a year. Cleaning procedures for those people should take about an hour. If they’re going in and they’re getting their teeth cleaned in 15 minutes, it’s grossly inadequate.
It’s important that our population understands that health care is changing a lot of the amount of time that people are allocated for professional care seems to be changing a lot. And it’s important that people who are at risk realize that they need a more specific kind of care. And if patients are really questioning whether they’re getting adequate care, then they may very well want to seek treatment by a periodontist. And, by training these individuals are much more focused on all of these kinds of risk factors and have a much deeper appreciation for the perio-systemic link here. We talk about diabetes, but people who have significant periodontal disease are also at greater risk for heart attack and stroke because of the inflammatory burden that it provokes.
RK: That’s interesting. For those who are at higher risk genetic risk of having periodontal disease, three to four times really intense one-hour sessions. And in addition to seeing their general dentist, seeing a periodontal specialist, such as yourself, might be beneficial. Is that right?
KZ: Yeah. If a person, if their general dentist, is indicating an increase in inflammation and probing depth. Then it would be prudent for that patient to seek management by a periodontist.
RK: And then for the general population of people with diabetes, who may, let’s say have average risk or just not a high risk, seeing their dentist twice a year, for 15 to 30 minute sessions. is adequate?
KZ: Generally not. What happens under those circumstances is that somebody is simply using a polishing cup and not really going below the gum line. You’ve raised a really good point. The biofilm is going to cause pocketing around the tooth. We use the analogy of fingernail and cuticle: when that seal is broken, bacterial populations are getting deeper and deeper into those tissues. And it really does require debridement or cleaning down below the gum line, either with hand instrumentation or ultrasonic instrumentation to clear that out. Simply polishing at the gum line itself is completely ineffective.
RK: It sounds like even for the general population of people with diabetes, it also requires more than just polishing. Really looking to see if there’s any pockets and more than, how long would you say they should expect a dental visit to last, if they have an adequate exam?
KZ: A minimum of 45 minutes. Unfortunately, insurance nowadays doesn’t afford people the opportunity to do that. But again, making sure that the population is aware of what these risk factors are and things that they can do to minimize their risk or mitigate these problems is essential. It’s really an emotional roller coaster for patients who have diabetes and periodontal disease and see them losing teeth and saying, “Can’t somebody help me?” The answer is “Absolutely,” but it has to go, outside the norm of normal dental treatment.
RK: And, specialists, such as yourself, are critical to helping people who have that advanced stage of periodontal disease. You mentioned some of the complications, which I think are important to emphasize, that it’s not just the periodontal disease and diabetes, but the higher risk of cardiovascular disease, other inflammatory conditions. What other complications can people see beyond the oral cavity because of this periodontal disease?
KZ: As we see inflammation and bone damage occurring, it becomes a two way street. The blood vessels around these areas of inflammation open up that immune cells can come in and try to battle. Once those portals and vessels open up, the endotoxins and the bacteria themselves can go into the bloodstream and literally shower the system with these toxins. We clearly have been able to identify atheromatous plaques in heart disease that harbor specific bacteria, particularly P. gingivalis. And they can go in and biopsy these things and find living bacteria in these atheromas. We can see the same thing occurring in the brain and apparently has some impact or increased risk for stroke and potentially Alzheimer’s. So, it’s the bacterial overgrowth in the oral cavity [that] creates an inflammatory burden. The important thing to understand is that in general, with effective treatment, we can control that inflammatory burden and take that portion of it off the table.
RK: It’s important to know that if left untreated, that the periodontal disease, the inflammation associated with it can travel beyond the mouth and the oral cavity to the brain, the heart, and really lead to complications there as well. [It]really underscores the importance of addressing this or preventing it from an early stage. One of the questions that I get from my patients, and I think perhaps some of our listeners might have is, “If I have diabetes, am I at a higher risk for having cavities?”
KZ: Yes. As we discussed earlier, particularly in the patient who’s not as compliant as we would like to see them. There’s going to be more of hyperglycemia that’s going to, again, create more of a micro nutritional base in the oral cavity, and that opens up the door for tooth decay. Diabetes also can decrease salivary flow. And as a result opens the door for tooth decay. Those are very definite factors that come into play, and clearly patients who are diabetic should be much more alert to their dental health overall.
RK: I think that is the important point that all of these conditions that we’re talking about really related to the teeth and gums are at a higher frequency in people with diabetes. They’re more likely to develop them. And really, this relies on the person with diabetes being more vigilant about their dental health, perhaps compared to people who don’t have diabetes.
Now, for those people who, despite preventative measures or because of lack of preventative measures or because they’re at higher risk, do develop periodontal disease, how is this usually treated? When you see someone in your practice, and clearly this will depend on what they come to see you for, but in general, is it medication? Is it surgery? What is usually the treatment for periodontal disease?
KZ: First and foremost, control the cause. When we’re dealing with dental issues, controlling the germ film is essential, which gets down ultimately to very effective oral hygiene. Once we’ve been able to develop that kind of behavioral pattern, we can do different kinds of procedures to clear out the germ film from below the gum line. Sometimes it’s as simple as a process called scaling and root planing. Noting that as the disease progresses down the root of a tooth, the root surface itself becomes toxic, and that root surface needs to be cleaned. There are times when we can intervene with laser therapy to detoxify the root surface, sterilize the root surface, the bone, and the gum tissue at the same time. And depending on how involved or progressed this disease becomes, surgical intervention is oftentimes necessary. But to that same point, a patient is diabetic; they typically don’t heal as well. You don’t have the same blood supply as you’d like in a non-diabetic patient.
They don’t heal as well and they heal slower. These are factors that come into play as well. Again, it’s your point that patients who are diabetic should be much more vigilant about their oral health.
RK: In particular to prevent these complications from happening, as you mentioned. And by the time perhaps that you see patients in your clinic, it might be too late in some cases, is that right? Some of the complications may require a surgical intervention?
KZ: That’s absolutely true. Not only that, but there, there are plenty of times when the disease has progressed far that you have to take the teeth out. That’s debilitating from a lot of different directions. People who can’t chew end up selecting a more dense carbohydrate diet. And if they’re diabetic, it makes it even worse. The inability to effectively chew to select [a] diet that is healthy also becomes a secondary component to this process.
RK: I think that’s so important to really keep in mind, that if not prevented, if not managed, if not treated appropriately, that there can be complications and surgery ultimately to remove teeth that can have significant consequences on day-to-day physical function and also quality of life. I think [it] further underscores the importance of proper dental hygiene and really being aware and vigilant about this potential condition that occurs more frequently in people with diabetes.
Dr. Zeren, we’ve learned much today from your expertise and really it’s been such a great discussion to really understand better why paying attention to our teeth and gums is so important, especially in a person with diabetes.
For those who are listening today, I wonder if you might have some parting words for them. In terms of, if they’re encouraged or inspired to really take better management of their dental hygiene, what would be the next steps that you would recommend for them?
KZ: Certainly, just having this kind of information is very helpful for them. Assuming that they’re diabetic, they should talk to their dental professional about the kinds of treatments that are necessary; tracking of inflammation in their mouths; bleeding; any increased in probing depth, these kinds of things people should be aware of and should frankly be asking their dental professionals about.
RK: I think that it’s important for the awareness that you have shared with us today and having that knowledge to bring it up to their primary care doctors and also their dentists is important. Dr. Zeren, thank you so much for your expertise and sharing all the great knowledge that you have shared with us today. I know that I’ve learned so much and I have no doubt that our listeners have as well. And hopefully we’ll be inspired to really take good care of their teeth and prevent these complications from occurring. Thank you again for being with us.
KZ: It’s been my pleasure. I really appreciate the opportunity, thank you.
RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit hopkinsdiabetesinfo.org.
We love to hear from our listeners. The email address is hopkinsdiabetesinfo@jhmi.edu.
Thanks for listening. Be well and see you next time.
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TranscriptEPISODE 36: Diabetes, Weight Management and Treatments for Obesity
Rita Kalyani: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani at Johns Hopkins. We developed this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy to understand resource for diabetes, or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.
We are thrilled to welcome back Dr. Marci Ladenslager, who will be talking about weight management and approaches to treatment. Dr. Laudenslager is an internal medicine and obesity medicine physician in the Johns Hopkins Healthful Eating Activity and Weight Program. She’s a diplomat of the American Board of Obesity Medicine, and her clinical expertise is in obesity and obesity associated disorders. She received her Doctor of Medicine degree from Drexel University College of Medicine and completed her internal medicine residency at the Hofstra Northwell Internal Medicine Residency Program, where she additionally served as chief resident. She became a Harvard Macy’s scholar during her year as chief resident. Dr. Laudenslager received her Master of Health Science degree from the Johns Hopkins Bloomberg School of Public Health and completed her general internal medicine fellowship training at the Johns Hopkins University School of Medicine. Welcome Dr. Laudenslager to our podcast.
Welcome Dr. Ladenslager
Marci Laudenslager: Thank you for having me. It’s such a pleasure to be here.
RK: Now, moving on to treatment, how do we address overweight and obesity in practice and specifically in people with diabetes. As I mentioned, this is a focus throughout our continuum from prediabetes to diabetes. We, we talk about lifestyle management all the time. But what does that really mean for you as a weight management specialist and obesity specialist?
What are the factors that we should be considering, or a person with diabetes should be considering, in their lifestyle management?
ML: Nutrition is something that we talk about a lot as is activity, but we mentioned a little bit about this earlier, sleep, stress, mental and emotional health, all such very important facets of, of lifestyle management.
I think that one of the first things that I do in my practice is sort of, unpack what we talk about culturally and separate that from the scientific evidence. That we’re not so anchored in just a nutrition and activity space. We really understand all facets of lifestyle because.
Sleep and stress, especially are very, very important and just as impactful on, on body weight as the other things that we’ve been talking about.
RK: I agree. I think that these are things we don’t talk about as much as we should. And we are beginning to recognize, I know for us in diabetes care, the importance of screening for sleep disturbances and, stress and mental health, and how that can impact also obesity and weight management. You talked about nutrition and exercise, which we have recommendations on routinely for, for people with diabetes, but I wonder if you wanted to talk a little bit about the societal view of obesity and perhaps the stigma that might be associated with that, that makes it difficult for people perhaps to accept and address in themselves. One of the things I’ll say, if I could, that I hear from my patients is, “I feel like I’m to blame, that it is my lifestyle habits that led to this.” And I think that also contributes to the challenges of managing weight. I just wondered, what you would say.
ML: I think the most important thing that I can say about that topic and about the way that we view obesity is, we really need to separate the cultural dialogue on this from the scientific evidence, so obesity is truly this chronic, highly complex metabolic disease. This is not a lifestyle choice. I think that culturally we’re taught to feel that and it’s difficult to unlearn some of what we’re taught culturally. It is very hard, and I think going back to those etiologies that we discussed before. There are many etiologies of obesity and many, many, many driving factors for weight gain. Understanding that I think is an important place to ground yourself and you’re thinking about experience with body weight. It goes so far beyond nutrition and activity, and it goes so far beyond that oversimplification of obesity as just a math equation; calorie balance in the day. It is very much not that our fat tissue is so dynamic, where you were dealing with a chronic metabolic condition that is based in hormones and there are so many of them and they talk to each other in a complex way. I describe this to folks in my practice as, a lively discussion amongst family members at Thanksgiving. There’s a lot of talk back and forth. There’s a lot of shouting over people. It really is complex the way that hormones interact in an obesity state. Beyond that, there are also these important. metabolic adaptations to weight loss that I think we don’t talk about enough. And what I mean by that is as the body is losing weight, our hunger hormone, ghrelin, goes up and our satisfaction hormones of which there are many, they go down. And that means that we are hungrier, and the body basically gets fewer calories in our calorie budget for the day, and that makes weight loss on its own difficult, but it’s also difficult to maintain weight loss for this reason, because of what’s going on with those hunger and satiety hormones.
As we’re losing weight, generally hungrier, and our metabolism rate goes down. The driver of our metabolism just so that folks know is really our muscle mass. As you’re losing weight, it’s important to maintain your muscle mass as you’re losing body fat, because if you’re losing your muscle, you lose your metabolism in a sense. You can simplify it that way. If your metabolism rate is going down, that makes long term weight maintenance very challenging. I think the biggest misconception about obesity is that it’s a lifestyle choice – it is not. That it is simple – it is not. That there are these quick fixes – there aren’t. Lots of different threads of dialogue out there. And I think, the obesity space is unique in medicine and that there’s a lot of misinformation and disinformation out there so that when you yourself are a patient at home looking for we used to help yourself through this.
It’s hard to unpack, what’s legitimate and what isn’t. It’s a really crowded space. And it’s really important to talk with your health providers about this so that you can understand for you as an individual, what are those things that are driving weight gain for you? I can’t tell you how many times I make a diagnosis of something like polycystic ovarian syndrome. There are genetic factors that are at play that, folks hadn’t talked. about before. It really is complicated. And for that reason, seeing an obesity specialist or an endocrinologist is really important to understand what those driving factors are.
That is the place where we start. Sometimes it’s something as simple as, Hey, I have a really, really, really challenging sleep problem. I’ve had insomnia for decades and I take Benadryl every night to go awake. Well, we have a major sleep issue there, which is going to cause a problem. And Benadryl is inherently waking promoting.
And so, somebody might be scratching their head at home thinking, “Hey, what’s going on? I’m highly active. My nutrition is super balanced. What is driving weight gain?” And the answer there is sleep. Number one and taking a weight gain promoting medicine Benadryl without knowing that that’s the effect the medication has.
It is highly complicated. I think really, really emphasizing that lifts the burden of responsibility. This is not a place of fault. This is a complex disorder that really needs to be deeply understood so that we can address those things that are driving weight gain and help folks move forward in their health.
RK: I think one of the things that I hear from what you’re saying and I think that maybe gets lost in the conversation, sometimes when we talk about weight management is the mental approach- what our psychological mindset is to approach some of the challenges, like you mentioned with stress and how it affects weight.
I wonder if you could talk a little bit about that. Cause I think there are many programs out there that really leverage that in terms of their ability to lead to weight loss. Could you talk about the role of some of our mental thinking approaches to weight management?
ML: We can talk about stress and anchor there for a second because I think that that does share real estate with a lot of other common topics and emotional health. Stress is like transient diabetes. Think about it that way when we’re under high levels of stress, especially if this goes on for a long time.
Our stress hormones, we can think about cortisol as a common one. It has many friends, cortisol and company. They all go up that can cause insulin resistance as well as changes in some of those other satiety metabolism hormones. The net effect of that is typically a decrease in our metabolic rate and an increase in our food intake because we’re much hungrier.
That is sometimes centered around this increase in what’s called “the hedonic drive,” which is basically that emotional feeling around foods. It’s centered in the the reward pathway. The emotional reward the body receives from taking in certain foods and that hedonic drive, that place of thinking that is more geared toward palatable foods.
That’s what it searches for basically comfort foods all of that taken together before under high levels of stress. Cortisol goes up, a whole bunch of other things happen hormonally, our metabolism rate suffers, we’re hungrier, and we’re hungrier for specific things. Those comfort foods that are typically those high calorie, ultra processed foods.
And with that, we typically can get an increase in that visceral fat as well. Thinking about stress that way is important and connecting that to sleep. We can do that easily as well because the body is see sleep disorders as a form of stress in a way if we’re not getting adequate sleep, our hunger hormone, ghrelin, goes up and our satiety hormones, things like leptin, they go down we’re hungrier, we’re less satisfied with the foods that we’re eating. One of the things that I typically use in my practice; this is a nice tool for, where do I start with managing some of the emotional connections to food; and let’s use stress as an example here: if I know for myself that stress is something that leads to cravings and, man, I’m always reaching for this particular food. How do I manage that? Think about something you can do and a few seconds, something you can do in a few minutes. And then another thing you can do in a few hours or the better part of it, the day and give yourself some indoor and outdoor options and write them down because that makes things a little bit more concrete. If we’re just thinking things in the mind, it seems a little bit more abstract and it’s hard to really use those things as a tool later think about those things with great intention and write them down and then the next time that you’re feeling stressed think about the environment that you’re in: Okay, I’m at work. I can’t do my outside thing But, I told myself that maybe one of my things was listening to a little bit of of music or doing like a puzzle or something like that., you have to find the thing that really speaks to you. Maybe it’s just taking some deep breaths because I’m in a meeting and I can’t do any of those other things.
So find something that can be there for you no matter what environmental situation that you’re in. And over time, the brain will start connecting those new activities to, hey, these relieve stress as well. It isn’t just that connection to food that exists that starts to disintegrate, and the brain learns a new, healthier habit.
Over time, this does take practice. Let’s take practice that it takes time. We can, number one, help with our levels of stress because we’re giving ourselves tangible tools for how to manage things. And we’re thinking about tools that are non-food or drink related we’re separating food and emotion in the brain, and that can be really helpful as well.
RK: Thanks for sharing those tools that you use in your practice because I think– and we’re going to talk next about the lifestyle changes and the medications, which are of course, very important–but what you are describing, which is the emotional reaction to food and the cravings and stress is very important and, for some people, may be a main driver. And so, I think that strategy of thinking of healthier habits that can replace the reward, the emotional reward, that people associate with food over time can be learned and I think that’s a practical tip that anybody can do in any environment thank you for sharing that.
Talking a little bit about lifestyle the logistics of that let’s start with diet. Is there a right diet for weight loss in diabetes or without diabetes? What would you say?
ML: Yeah, I love this question because this is probably the number one question that comes up clinically.
Is there a right way to eat? And the short answer to this is no. And if we look at decades of research, and we look at those studies that have taken specific nutrition plans, fad diets especially, line them all up, put them head-to-head and see which one is the best for weight management, at the end of the day, they’re all the same. It is the sustainability of a nutrition plan that is going to help folks be successful long term. I think when we’re talking about diabetes, there are a number of evidence based based nutrition styles that can help lower blood sugar. And I’m thinking about, a lower carbohydrate diet.
And that means a lot of different things. Generally, can think about that as being 25 to 45 percent of total daily calories from carbs, but again, there are lots of ways to follow a lower carb plan, a plant based. Diet can also be helpful in lowering A1C or blood sugar that’s vegan or vegetarian, both of those will be effective in that way.
And the Mediterranean nutrition style can be helpful. But I think that, what all of those have in common, when we think about, plant based, Mediterranean the DASH diet is another nutrition style that comes up a lot in research studies and in health. And that stands for the dietary approaches to stop hypertension.
So that’s one we usually use in the blood pressure management space. But if we look at the common principles to all of those evidence-based nutrition styles. One thing stands out and that they’re all whole foods based, they emphasize lean proteins, fruits, veggies, whole grains, and they minimize things like sweets and ultra-processed foods.
There are so many healthy, balanced evidence-based nutrition styles out there. I think this is where, especially if you are managing diabetes, it’s really important to meet with a dietitian or talk to your provider about a personalized plan, knowing that, yes, this whole foods approach, that can be applied in a number of different ways, but there’s no right diet per se. It’s really about finding that sustainable lifestyle plan that will support you in your health goals long term. It’s the sustainability part of it that really is more important.
RK: I think that the sustainability part will be a theme as we talk about medications and potentially surgery as well in terms of getting the weight off but keeping the weight off as well. Moving on to exercise, you mentioned the importance of ensuring that even with weight loss, that the muscle mass is preserved. And as you noted that if you have a calorie deficit, you’re going to lose both fat and muscle and it’s important to maintain that muscle mass. What exercise regimen do you usually recommend for people to maintain that healthy balance of muscle when they’re losing weight?
ML: I typically start by asking folks, where they are in terms of their health goals. If we’re in the weight loss phase, cardio will tend to lower body fat more so than resistance training. If we’re really anchoring in that weight loss maintenance phase, then exactly as you say, that preservation of lean muscle becomes really important because that helps support our resting metabolic rate.
So activity will increase insulin sensitivity and leptin sensitivity. These are all things that in the brain can help lower our appetite and keep our metabolism healthy. All activity will help with cardiovascular risk or heart health. It will help decrease inflammation. It really is about picking the style of activity that matches with what, your health goals are right at that moment. If we’re working really on weight loss, I typically emphasize cardio at the beginning, maybe more so than resistance training. And then, we flip things around when we get farther down the line. We want to really be able to maintain that weight that you’ve been working so hard to lose they’re both important. They just act differently. It’s important to know though that weight loss from exercise alone is typically modest. We use activity and we partner that with, other lifestyle strategies like medications, like surgery, depending on, that particular individual, but knowing the benefits of activity overall. You can use them in those phases appropriately, but at the end of the day, pick something that really, sparks joy, because I think the one thing that can be a barrier to activity is thinking about, what it should be. What’s the ideal? There’s no “should.” There just “is”. What do you like to do? What would you like to do more of? And starting from, from that space, what are you able to do? It really is thinking about the individual person and what brings them joy, what helps with their energy, what helps with their sleep. Activity can do all these things. Getting outside and just moving your body can help with mental and emotional health. It can help with sleep health. Thinking about it as a lifestyle strategy that just boosts overall health and wellness of quality of life- that’s usually where I put my focus and we start where we start, and you can gradually build up over time or change things depending on what the health goals are.
But, when it comes to muscle mass, it is important that we preserve that throughout the journey for, those metabolic reasons we were talking about. We want to make sure you’ve worked so hard to lose body weight. We preserve your muscles so that you can keep the weight off long-term.
RK: Really it should be activity that aligns with the individual’s own priorities in terms of what they want to do. And then the balance of cardio exercise to muscle strength and exercise as well, which should be individualized or really aligned to where they are in their weight loss journey.
Moving now to medications, which is really in many ways, the hot topic these days. What medications are available for people who have tried these other strategies? Let’s say that lifestyle strategies, the emotional regulation, the stress management, and they’re still not successful. And who is eligible as candidates for the weight loss medications?
ML: There are a number of medications available to help treat overweight and obesity, and they range from pills that you take to injections. I think that those are getting a lot of attention right now. We can certainly talk about those. When we talk about oral medications for weight loss; pills that you can take. The oldest one that I can think about is phentermine and that was FDA approved for weight loss in 1959 this one has been been around for a very long time that is a mild stimulant. It will act as an appetite suppressant. There are combination pills. One that actually includes phentermine – a medicine called Qsymia, which is a combination of phentermine and topiramate; also goes by the name Topamax. Another combination pill called Contrave, which is also the mix of 2 medicines: bupropion and naltrexone. Those can give a little bit of metabolism support and they will typically be experienced as an appetite suppressant for folks, but it is doing other stuff in terms of metabolic support, a mild stimulant effect. When we get to the injection medicines, these are the newer generations or weight loss drugs. And the one that I’m thinking about in particular, are those ones that work on GLP1. That stands for “Glucagon-like Peptide One”. These are the injections that you probably see on social media, on the news. These target a really important satiety hormone, GLP1’s. That helps manage weight but also helps regulate blood sugar there really are a number of options or more options I think than folks think about actually, because some are more popular than others right now. They’re just getting more media attention. Doesn’t mean the other ones are not effective. It just means they’re not getting as much media attention. But weight loss medicines have been around for a long time and, talking with your physician about which one may be right for you, I think is important because there are a number of contraindications to certain medicines for example, folks with certain heart conditions wouldn’t be candidates for some of these stimulant medications, you have to know which one is the safest for you to take and which one is going to be the most appropriate. Some of the ones that we talked about can really help with cravings, or hunger at night, or we can use them and tailor them to hunger that happens at a very specific time of day.
So all of that is to say, there are lots of options that can be really tailored to the individual experience and that will be safe for that person. That really is the most important thing. What’s going to be safest and what’s going to be the most effective for your particular experience with your health and your body weight for folks who are candidates for these medications. It’s those who have. a BMI of 30 or greater, or those who have a BMI of 27 or greater, generally speaking, plus a weight associated condition, like diabetes, like hypertension. Although there are others that fall out of, those definitions, that’s the most classic definition of, who can use one of these weight loss drugs.
So, I can talk a little bit more about those injection medicines, because I think that that comes up a lot. I think the one thing that I get asked the most is, why do we use these medicines, the injection ones per se, the GLP ones? Why do we use those in obesity? They’re classically used in diabetes. Why do they also work here? In obesity, post prandial GLP 1, is decreased all of that means the sense of satisfaction that you get during or after your meals is impaired. That is what happens as body weight goes up when we use these injection medicines in obesity, that dysfunctional satisfaction signal is corrected. You appropriately experience fullness with your meals. Those medicines will also increase your energy expenditure, how many calories you burn, going about your day-to-day life. And they have the same effects that are beneficial in diabetes. They affect those hormones that regulate blood sugar.
Diabetes and weight management share hormones in common. And when we use medicines that target, target those certain hormones, that’s why one medicine can work in a bunch of different spaces. It really is important to highlight that, weight management. Heart disease, liver issues, diabetes… there are so many hormones that are shared and that’s why those medications are shared in those different spaces. And that’s what we want from a drug we want it to be impactful for as many things as possible. That’s why you see things like semaglutide; it goes by the brand names Ozempic and Wegovy. That’s why we see it being used for lots of different things because there are these shared hormones with different disease states and that’s why we get benefit across the board in a lot of these different areas.
RK: And you mentioned Ozempic or Wegovy, which is semaglutide some others just to round out the class might include dulaglutide or brand name Trulicity or liraglutide (brand name Victoza or Saxenda). These are medications, like you mentioned some are approved for diabetes and some are approved at the higher doses for obesity. A question that I often get asked is when you use these medications for obesity, any of the medications that you’ve talked about, whether GLP-1s or the other medications that you talked about, how long do you continue on them? And what happens when you stop? Do you regain that weight?
ML: With medications for weight management, I typically frame these as chronic use medicine. Medicines that you’re going to be on long-term because obesity is a chronic metabolic disease, and I view it just like Type 2 diabetes or hypertension. We use hypertension, for example, some folks will, follow the lowest salt diet you can even think about. But there are other things in their family history, their genetics that just predispose them to having a higher blood pressure they need a blood pressure medicine to manage that; to couple with their lifestyle efforts. That makes things better. And if down the line, we take the medicine away, what’s going to happen? Their blood pressure is going to go back up because those underlying things that we can’t control, like their genetic factors are still there with weight management, it’s important to think about the chronic metabolic disease definition and center the way that we use medications in that space. They really are meant to be used long term. Not to say that can’t go off of them, down the line, you absolutely can, but you need to be working with a weight management specialist to do that. The one thing that I think gets confusing in the current cultural conversation around these newer medicines in particular, is that there is a concern that if I stop this medicine, is there a rebound effect?
Am I more susceptible to weight regain because of something that the medicine is doing. And the short answer to that is no, it really is about understanding what things are contributing to weight gain in the first place and are they still there? For someone with polycystic ovarian syndrome, that’s something they’re going to have for a while.
So using a medicine to help control that will help manage their weight. And if you go off of that, Weight management medicine than the weight gain that comes with polycystic ovarian syndrome will come back So it is more nuanced in that way, for someone who has Insomnia someone who is under chronic stress for someone who had like all of the etiologies those causes of weight gain that we Talked about before if those things are still there. They will continue to contribute to weight gain I think a really important example of this is those who are on medicines that cause weight gain, and they need to be on them. Insulin is one example, but there are many others. There are certain cancer medications that cause weight gain, and we of course need to continue those.
There are mental health medications that folks need to be on, and they cause weight gain, but they need to continue them. When that’s the case, a weight loss medicine is critical because the thing that’s going on in the background that caused weight to go up in the first place is still there. There’s nothing inherently about the weight loss medicine that creates this rebound effect. It’s just about understanding what affects weight gain. And if those factors are still present, you take the medicine away. Weight will come back on for those reasons. It’s a little bit subtle and nuanced, but yes long-term medicines for most of these is typically the way that I use them.
RK: It makes sense that you really do have to address the underlying factors contributing to why you’re gaining weight in the first place. And you mentioned that the newer agents, particularly are really ones that can be used chronically especially if there are underlying factors.
But as I understand that the stimulants are really designed to be used just for a few months at a time. Is that right? Some of the older medicines?
ML: That’s a state-by-state question. When you’re a provider, it’s important to know the laws of your state, because the evidence supports long term use of stimulants like Phentermine, but in some states, it is still only approved for short term use. And by short term use, I mean three months or less. There is a discrepancy by what is supported by the literature and what is still listed in FDA guidelines and how the states interpret those things. All of that is to say, we can absolutely safely use the stimulant medications long term. Guidelines support that use, but that isn’t always possible depending on where you live. That all said. It’s important to be closely monitored when you’re on any of these medications because we want to make sure that you’re safe and supported while you’re on these drugs. It’s important to monitor blood pressure and heart rate and things like that. A good example of the long-term use. Phentermine, for example, is in one of those combination pills we talked about, Qsymia, that’s approved for long term use. It really just is about the way that the medications are labeled at the federal and the state level. My feeling about this is that the current labeling guidelines are not necessarily up to date with the current science of weight loss. My hope is that the labeling catches up to that. But that is where that confusion point comes from. I use these medicines long term in my practice, provided that, folks meet criteria to do that safely, but that will vary significantly state to state, depending on what those state laws are.
RK: That’s really good to know thanks for going over that. We didn’t have the chance to really go into the side effects of some of these newer medications like the GLP 1s. I think that the GI side effects and also the cost tend to be limiting factors on an individual basis something also to keep in mind.
Lastly, I think we probably don’t need to go into great detail about surgery, but I wonder if you could briefly talk about whom you might consider for surgery if the lifestyle changes, and the, and the medical management isn’t achieving the desired goals.
ML: Sure, the surgical guidelines have actually changed, and I can highlight that evolution and who is eligible for bariatric surgery it used to be that folks would need to have a BMI of 40 kg/m2 or greater or 35 kg/m2 or greater plus a weight related disorder like diabetes like hypertension.
The new guidelines say that bariatric surgery should be considered for those with a BMI of 30 to 35 kg/m2 class one obesity and in folks who have that BMI, but have not achieved significant or durable weight loss or a comorbidity improvement with non-surgical methods like lifestyle management or pharmacotherapy medications. And then for everyone who has a BMI of 35 kg/m2 or greater with or without a weight associated comorbidity, they would also be eligible there is basically this shift downward by five BMI points.
It’s important to note that while these guidelines have recently been updated, and I think that it’s great to be able to offer surgery to folks who would benefit from it, not all insurance companies have quite adopted this new guideline statement. For that reason, not all surgeons are offering bariatric surgery at those lower BMI thresholds. But in time, that will be the new standard. Right now, we typically will talk about surgery with those old cutoffs, 40 or above, or 35 and above with a weight associated comorbidity. If someone has really difficult to manage diabetes, for example, and their BMI is 32 kg/m2, and their insurance will cover a bariatric procedure, we absolutely will talk about that. Because we’re in this transition space of guidelines, it really does require talking to each individual person and saying, ” what are your health goals? Is this something that you really want to consider at a lower BMI threshold? Is insurance going to cover it? Is it affordable for you?” it’s important to make sure that we address that. All of those things Surgery is a wonderful tool, with the sleeve gastrectomy, which is, one of the more common procedures you can expect to lose 20 to 25 percent of body weight with the gastric bypass or the Roux-en-Y, so to speak 30 to 40%. With diabetes, if we’re talking about that specific example, we can get remission. of diabetes with surgery, 29 percent of those who have a bypass and 23 percent of those who have a sleeve. All that is to say they’re very effective. When we’re looking at how surgery intersects with the evolving landscape of medications, it is actually very exciting because some of the new drugs that we’re using for diabetes and for weight loss are approaching how effective surgery is.
I think that that is going to continue to happen. That we have medicines that are valuable in a similar way to bariatric surgery somebody would qualify by newer guidelines, but their insurance won’t cover it, then, they’re an incredible candidate for some of the, the stronger anti-obesity like some of the newer generation injection drugs that we were talking about.
RK: I agree. It’ll be interesting to see in the years to come how some of our medications may approach the outcomes that we see with surgery and remission, like you mentioned for diabetes. It’s something that we may not have talked about a few decades ago, and to think that surgery or even some of the medications that we have now could lead to remission of diabetes, not having diabetes at all anymore is pretty amazing, in some people that that could be seen. Of course, with any surgery, there are potential procedural complications that we need to be aware about, but in general, in the hands of an expert it can be done safely particularly in, in huge surgery centers. Absolutely.
As we round out our conversation today and thank you so much for taking the time to talk with us about this important topic, I was wondering what you would say to a person who’s listening today who might be struggling with their weight loss goals and really feeling discouraged in terms of what they’ve been able to accomplish.
How do you counsel your patients who are beginning or are struggling with their weight loss journey in terms of what they can attain and what is feasible in the short and long term.
ML: The first thing that I’ll say is that this is hard. We’ve been talking a lot about this complex conversation with metabolism hormones. It can get really deep when we talk about what causes weight management challenges and, makes them more difficult to kind of manage over time. It’s really important to understand the complexity of all of this and how much it sometimes feels like folks who are struggling are at odds with their hormones.
They’re sort of fighting it. against them in a way, ” Hey, my body’s not really doing what I wanted to do. What’s going on?” This is a really complex disorder. It is absolutely manageable with a healthcare partner who, can really kind of help you navigate what has been the key contributor to weight gain, and then we can understand how to provide support going forward. It is difficult. This is a lifelong journey for so many folks who are not alone. For those reasons, it’s important to seek out expert care so that we can understand, is there another medical condition that’s contributing? Is there a medication that you’re taking that’s making this a little bit harder? Are there lifestyle habits that we can give support around? Are there other medical conditions that we can help manage? Just think through your lifelong journey and know that you’re not alone in this. There are absolutely folks who it is our job. It is our pleasure to help. That is what we are here to do. And there are so many ways that we can help with weight management and help with long-term sustainable weight loss for the providers out there, I think it’s important to really listen to folks, listen to the lifestyle journey. I learned so much from my patients just sort of asking, can you walk me through your journey. That can tell me so much. Then once I understand your journey, that’s when I can understand, how do I begin to provide support? How do we begin to help make weight management a little bit more approachable and how can I give you support long-term and give you back your quality of life? Seeking health care support from an expert I think is truly important just because it’s really complex as we’ve been talking through. We as providers are here to offer compassion and supportive guidance, never judgment. That is a key takeaway for my practice.
RK: Well, thank you so much, Dr. Laudenslager, for being here today, for sharing your expert perspectives on weight management and obesity, specifically in diabetes and the non-judgmental compassionate care that’s so important for long term success and the different options that individuals have in terms of managing and approaching challenges with weight management. Thank you again for being here today.
ML: It’s been such a pleasure. Thank you for having me.
RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit hopkinsdiabetesinfo.org. We love to hear from our listeners. The email address is hopkinsdiabetesinfo@jhmi.edu. Thanks for listening. Be well and see you next time.
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- Home - | - Episode 36: Diabetes , Weight Management and Treatments for ObesityIn Episode 35, Dr. Kalyani welcomes Marci Laudenslager, MD MHS DABOM. Dr. Laudenslager is an internal medicine and obesity medicine physician in the Johns Hopkins Healthful Eating, Activity & Weight Program. She is a Diplomate of the American Board of Obesity Medicine and her clinical expertise is in obesity and obesity-associated disorders. She was recognized as a “Top Weight Management Doctor” by Baltimore Magazine in 2021, 2022, and 2023. Dr. Laudenslager is a clinician educator and researcher – her work is specifically focused on the educational gap that exists in obesity medicine. She teaches learners at all levels of medical training and designs curricula aimed at improving obesity medical education. Dr. Laudenslager received her doctor of medicine degree from Drexel University College of Medicine. She completed her internal medicine residency at the Hoftra Northwell Internal Medicine Residency Program where she additionally served as Chief Resident. She became a Harvard Macy Scholar during her year as Chief Resident. Dr. Laudenslager received her Master of Health Science degree from The Johns Hopkins Bloomberg School of Public Health and completed her General Internal Medicine Fellowship training at The Johns Hopkins University School of Medicine.
TranscriptEPISODE 36: Diabetes, Weight Management and Treatments for Obesity
Rita Kalyani: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani at Johns Hopkins. We developed this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy to understand resource for diabetes, or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.
We are thrilled to welcome back Dr. Marci Ladenslager, who will be talking about weight management and approaches to treatment. Dr. Laudenslager is an internal medicine and obesity medicine physician in the Johns Hopkins Healthful Eating Activity and Weight Program. She’s a diplomat of the American Board of Obesity Medicine, and her clinical expertise is in obesity and obesity associated disorders. She received her Doctor of Medicine degree from Drexel University College of Medicine and completed her internal medicine residency at the Hofstra Northwell Internal Medicine Residency Program, where she additionally served as chief resident. She became a Harvard Macy’s scholar during her year as chief resident. Dr. Laudenslager received her Master of Health Science degree from the Johns Hopkins Bloomberg School of Public Health and completed her general internal medicine fellowship training at the Johns Hopkins University School of Medicine. Welcome Dr. Laudenslager to our podcast.
Welcome Dr. Ladenslager
Marci Laudenslager: Thank you for having me. It’s such a pleasure to be here.
RK: Now, moving on to treatment, how do we address overweight and obesity in practice and specifically in people with diabetes. As I mentioned, this is a focus throughout our continuum from prediabetes to diabetes. We, we talk about lifestyle management all the time, but what does that really mean for you as a weight management specialist and obesity specialist?
What are the factors that we should be considering or a person with diabetes should be considering In their, “lifestyle management.”
ML: Nutrition is something that we talk about a lot as is activity, but we mentioned a little bit about this earlier, sleep, stress, mental and emotional health, all such very important facets of, of lifestyle management.
I think that one of the first things that I do in my practice is sort of, unpack what we talk about culturally and separate that from the scientific evidence. That we’re not so anchored in. Just a nutrition and activity space. We really understand all facets of lifestyle because.
Sleep and stress, especially very, very important and just as impactful on, on body weight as the other things that we’ve been talking about.
RK: I agree. I think that these are things we don’t talk about as much as we should. And we are beginning to recognize, I know for us and diabetes care. The importance of screening for sleep disturbances and, stress and mental health and how that can impact also obesity and weight management. You talked about nutrition and exercise, which we have recommendations on routinely for, for people with diabetes, but I wonder if you wanted to talk a little bit about the societal view of obesity and perhaps the stigma that might be associated with that, that makes it difficult for people perhaps to accept and address in themselves. One of the things I’ll say, if I could, that I hear from my patients is, I feel like I’m to blame, that it is my lifestyle habits that led to this.” And I think that also contributes to the challenges of managing weight. I just wondered, what you would say.
ML: I think the most important thing that I can say about that topic and about the way that we view obesity is, we really need to separate the cultural dialogue on this from the scientific evidence, so obesity is truly this chronic, highly complex metabolic disease. This is not a lifestyle choice. I think that culturally we’re taught to feel that and it’s difficult to unlearn some of what we’re taught culturally. It is very hard, and I think going back to those etiologies that we discussed before. There are many etiologies of obesity and many, many, many driving factors for weight gain. Understanding that I think is an important place to ground yourself and you’re thinking about experience with body weight. It goes so far beyond nutrition and activity, and it goes so far beyond that oversimplification of obesity as just a math equation; calorie balance in the day. It is very much not that our fat tissue is so dynamic, where you were dealing with a chronic metabolic condition that is based in hormones and there are so many of them and they talk to each other in a complex way. I describe this to folks in my practice as, a lively discussion amongst family members at Thanksgiving. There’s a lot of talk back and forth. There’s a lot of shouting over people. It really is complex the way that hormones interact in an obesity state. Beyond that, there are also these important. metabolic adaptations to weight loss that I think we don’t talk about enough. And what I mean by that is as the body is losing weight, our hunger hormone, ghrelin, goes up and our satisfaction hormones of which there are many, they go down. And that means that we are hungrier, and the body basically gets fewer calories in our calorie budget for the day, and that makes weight loss on its own difficult, but it’s also difficult to maintain weight loss for this reason, because of what’s going on with those hunger and satiety hormones.
As we’re losing weight, generally hungrier, and our metabolism rate goes down. The driver of our metabolism just so that folks know is really our muscle mass. As you’re losing weight, it’s important to maintain your muscle mass as you’re losing body fat, because if you’re losing your muscle, you lose your metabolism in a sense. You can simplify it that way. If your metabolism rate is going down, that makes long term weight maintenance very challenging. I think the biggest misconception about obesity is that it’s a lifestyle choice – it is not. That it is simple – it is not. That there are these quick fixes – there aren’t. Lots of different threads of dialogue out there. And I think, the obesity space is unique in medicine and that there’s a lot of misinformation and disinformation out there so that when you yourself are a patient at home looking for we used to help yourself through this.
It’s hard to unpack, what’s legitimate and what isn’t. It’s a really crowded space. And it’s really important to talk with your health providers about this so that you can understand for you as an individual, what are those things that are driving weight gain for you? I can’t tell you how many times I make a diagnosis of something like polycystic ovarian syndrome. There are genetic factors that are at play that, folks hadn’t talked. about before. It really is complicated. And for that reason, seeing an obesity specialist or an endocrinologist is really important to understand what those driving factors are.
That is the place where we start. Sometimes it’s something as simple as, Hey, I have a really, really, really challenging sleep problem. I’ve had insomnia for decades and I take Benadryl every night to go awake. Well, we have a major sleep issue there, which is going to cause a problem. And Benadryl is inherently waking promoting.
And so, somebody might be scratching their head at home thinking, “Hey, what’s going on? I’m highly active. My nutrition is super balanced. What is driving weight gain?” And the answer there is sleep. Number one and taking a weight gain promoting medicine Benadryl without knowing that that’s the effect the medication has.
It is highly complicated. I think really, really emphasizing that lifts the burden of responsibility. This is not a place of fault. This is a complex disorder that really needs to be deeply understood so that we can address those things that are driving weight gain and help folks move forward in their health.
RK: I think one of the things that I hear from what you’re saying. And I think that maybe get lost, gets lost in the conversation, sometimes when we talk about weight management is the mental approach- how we what our psychological mindset is to approach some of the challenges, like you mentioned with stress and how it affects weight.
I wonder if you could talk a little bit about that. Cause I think there are many programs out there that really leverage that in terms of their ability to lead to weight loss. Could you talk about the role of some of our mental thinking approaches to weight management?
ML: We can talk about stress and anchor there for a second because I think that that does share real estate with a lot of other common topics and emotional health. Stress is like transient diabetes. Think about it that way when we’re under high levels of stress, especially if this goes on for a long time.
Our Stress hormones, we can think about cortisol as a common one. It has many friends, cortisol and company. They all go up that can cause insulin resistance as well as changes in some of those other satiety metabolism hormones. The net effect of that is typically a decrease in our metabolic rate and an increase in our food intake because we’re much hungrier.
That is sometimes centered around this increase in what’s called “the hedonic drive,” which is basically that emotional feeling around foods. It’s centered in the the reward pathway. The emotional reward the body receives from taking in certain foods and that hedonic drive, that place of thinking that is more geared toward palatable foods.
That’s what it searches for basically comfort foods all of that taken together before under high levels of stress. Cortisol goes up, a whole bunch of other things happen hormonally, our metabolism rate suffers, we’re hungrier, and we’re hungrier for specific things. Those comfort foods that are typically those high calorie, ultra processed foods.
And with that, we typically can get an increase in that visceral fat as well. Thinking about stress that way is important and connecting that to sleep. We can do that easily as well because the body is see sleep disorders as a form of stress in a way if we’re not getting adequate sleep, our hunger hormone, ghrelin, goes up and our satiety hormones, things like leptin, they go down we’re hungrier, we’re less satisfied with the foods that we’re eating. One of the things that I typically use in my practice; this is a nice tool for, where do I start with managing some of the emotional connections to food; and let’s use stress as an example here: if I know for myself that stress is something that leads to cravings and, man, I’m always reaching for this particular food. How do I manage that? Think about something you can do and a few seconds, something you can do in a few minutes. And then another thing you can do in a few hours or the better part of it, the day and give yourself some indoor and outdoor options and write them down because that makes things a little bit more concrete. If we’re just thinking things in the mind, it seems a little bit more abstract and it’s hard to really use those things as a tool later think about those things with great intention and write them down and then the next time that you’re feeling stressed think about the environment that you’re in: Okay, I’m at work. I can’t do my outside thing But, I told myself that maybe one of my things was listening to a little bit of of music or doing like a puzzle or something like that., you have to find the thing that really speaks to you. Maybe it’s just taking some deep breaths because I’m in a meeting and I can’t do any of those other things.
So find something that can be there for you no matter what environmental situation that you’re in. And over time, the brain will start connecting those new activities to, hey, these relieve stress as well. It isn’t just that connection to food that exists that starts to disintegrate, and the brain learns a new, healthier habit.
Over time, this does take practice. Let’s take practice that it takes time. We can, number one, help with our levels of stress because we’re giving ourselves tangible tools for how to manage things. And we’re thinking about tools that are non-food or drink related we’re separating food and emotion in the brain, and that can be really helpful as well.
RK: Thanks for sharing those tools that you use in your practice. Cause I think, we’re going to talk next about the lifestyle changes and the medications, which are of course, very important, but what you are describing, which is the emotional reaction to food and the cravings and stress is very important. For some people may be a main driver. And so, I think that strategy of thinking of healthier habits that can replace The reward that the emotional reward that people associate with food over time can be learned and I think that’s A practical tip that anybody can do in any environment thank you for sharing that.
Talking a little bit about lifestyle the logistics of that let’s start with diet. Is there a right diet for weight loss in diabetes or without diabetes? What would you say?
ML: Yeah, I love this question because this is probably the number one question that comes up clinically.
Is there a right way to eat? And the short answer to this is no. And if we look at decades of research, and we look at those studies that have taken specific nutrition plans, fad diets especially, line them all up, put them head-to-head and see which one is the best for weight management, at the end of the day, they’re all the same. It is the sustainability of a nutrition plan that is going to help folks be successful long term. I think when we’re talking about diabetes, there are a number of evidence based based nutrition styles that can help lower blood sugar. And I’m thinking about, a lower carbohydrate diet.
And that means a lot of different things. Generally, can think about that as being 25 to 45 percent of total daily calories from carbs, but again, there are lots of ways to follow a lower carb plan, a plant based. Diet can also be helpful in lowering A1C or blood sugar that’s vegan or vegetarian, both of those will be effective in that way.
And the Mediterranean nutrition style can be helpful. But I think that, what all of those have in common, when we think about, plant based, Mediterranean the DASH diet is another nutrition style that comes up a lot in research studies and in health. And that stands for the dietary approaches to stop hypertension.
So that’s one we usually use in The blood pressure management space. But if we look at the common principles to all of those evidence-based nutrition styles. One thing stands out and that they’re all whole foods based, they emphasize lean proteins, fruits, veggies, whole grains, and they minimize things like sweets and ultra-processed foods.
There are so many healthy, balanced evidence-based nutrition styles out there. I think this is where, especially if you are managing diabetes, it’s really important to meet with a dietitian or talk to your provider about a personalized plan, knowing that, yes, this whole foods approach, that can be applied in a number of different ways, but there’s no right diet per se. It’s really about finding that sustainable lifestyle plan that will support you in your health goals long term. It’s the sustainability part of it that really is more important.
RK: I think that sustainability part will be a theme as we talk about medications and potentially surgery as well in terms of getting the weight off but keeping the weight off as well. Moving on to exercise, you mentioned the importance of ensuring that even with weight loss, that the muscle mass is preserved. And as you noted that if you have a calorie deficit, you’re going to lose both fat and muscle and it’s important to maintain that muscle mass. What exercise regimen do you usually recommend for people to maintain that healthy balance of muscle when they’re losing weight?
ML: I typically start by asking folks, where they are in terms of their health goals. If we’re in the weight loss phase, cardio will tend to lower body fat more so than resistance training. If we’re really anchoring in that weight loss maintenance phase, then exactly as you say, that preservation of lean muscle becomes really important because that helps support our resting metabolic rate.
So activity will increase insulin sensitivity and leptin sensitivity. These are all things that in the brain can help lower our appetite and keep our metabolism healthy. All activity will help with cardiovascular risk or heart health. It will help decrease inflammation. It really is about picking the style of activity that matches with what, your health goals are right at that moment. If we’re working really on weight loss, I typically emphasize cardio at the beginning, maybe more so than resistance training. And then, we flip things around when we get farther down the line. We want to really be able to maintain that weight that you’ve been working so hard to lose they’re both important. They just act differently. It’s important to know though that weight loss from exercise alone is typically modest. We use activity and we partner that with, other lifestyle strategies like medications, like surgery, depending on, that particular individual, but knowing the benefits of activity overall. You can use them in those phases appropriately, but at the end of the day, pick something that really, sparks joy, because I think the one thing that can be a barrier to activity is thinking about, what it should be. What’s the ideal? There’s no “should.” There just “is”. What do you like to do? What would you like to do more of? And starting from, from that space, what are you able to do? It really is thinking about the individual person and what brings them joy, what helps with their energy, what helps with their sleep. Activity can do all these things. Getting outside and just moving your body can help with mental and emotional health. It can help with sleep health. Thinking about it as a lifestyle strategy that just boosts overall health and wellness of quality of life- that’s usually where I put my focus and we start where we start, and you can gradually build up over time or change things depending on what the health goals are.
But, when it comes to muscle mass, it is important that we preserve that throughout the journey for, those metabolic reasons we were talking about. We want to make sure you’ve worked so hard to lose body weight. We preserve your muscles so that you can keep the weight off long-term.
RK: Really it should be activity that aligns with the individual’s own priorities in terms of what they want to do. And then the balance of cardio exercise to muscle strength and exercise as well, which should be individualized or really aligned to where they are in their weight loss journey.
Moving now to medications, which is really in many ways, the hot topic these days. What medications are available for people who have tried these other strategies? Let’s say that lifestyle strategies, the emotional regulation, the stress management, and they’re still not successful. And who is eligible as candidates for the weight loss medications?
ML: There are a number of medications available to help treat overweight and obesity, and they range from pills that you take to injections. I think that those are getting a lot of attention right now. We can certainly talk about those. When we talk about oral medications for weight loss; pills that you can take. The oldest one that I can think about is phentermine and that was FDA approved for weight loss in 1959 this one has been been around for a very long time that is a mild stimulant. It will act as an appetite suppressant. There are combination pills. One that actually includes phentermine – a medicine called Qsymia, which is a combination of phentermine and topiramate; also goes by the name Topamax. Another combination pill called Contrave, which is also the mix of 2 medicines: bupropion and naltrexone. Those can give a little bit of metabolism support and they will typically be experienced as an appetite suppressant for folks, but it is doing other stuff in terms of metabolic support, a mild stimulant effect. When we get to the injection medicines, these are the newer generations or weight loss drugs. And the one that I’m thinking about in particular, are those ones that work on GLP1. That stands for “Glucagon-like Peptide One”. These are the injections that you probably see on social media, on the news. These target a really important satiety hormone, GLP1’s. That helps manage weight but also helps regulate blood sugar there really are a number of options or more options I think than folks think about actually, because some are more popular than others right now. They’re just getting more media attention. Doesn’t mean the other ones are not effective. It just means they’re not getting as much media attention. But weight loss medicines have been around for a long time and, talking with your physician about which one may be right for you, I think is important because there are a number of contraindications to certain medicines for example, folks with certain heart conditions wouldn’t be candidates for some of these stimulant medications, you have to know which one is the safest for you to take and which one is going to be the most appropriate. Some of the ones that we talked about can really help with cravings, or hunger at night, or we can use them and tailor them to hunger that happens at a very specific time of day.
So all of that is to say, there are lots of options that can be really tailored to the individual experience and that will be safe for that person. That really is the most important thing. What’s going to be safest and what’s going to be the most effective for your particular experience with your health and your body weight for folks who are candidates for these medications. It’s those who have. a BMI of 30 or greater, or those who have a BMI of 27 or greater, generally speaking, plus a weight associated condition, like diabetes, like hypertension. Although there are others that fall out of, those definitions, that’s the most classic definition of, who can use one of these weight loss drugs.
So, I can talk a little bit more about those injection medicines, because I think that that comes up a lot. I think the one thing that I get asked the most is, why do we use these medicines, the injection ones per se, the GLP ones? Why do we use those in obesity? They’re classically used in diabetes. Why do they also work here? In obesity, post prandial GLP 1, is decreased all of that means the sense of satisfaction that you get during or after your meals is impaired. That is what happens as body weight goes up when we use these injection medicines in obesity, that dysfunctional satisfaction signal is corrected. You appropriately experience fullness with your meals. Those medicines will also increase your energy expenditure, how many calories you burn, going about your day-to-day life. And they have the same effects that are beneficial in diabetes. They affect those hormones that regulate blood sugar.
Diabetes and weight management share hormones in common. And when we use medicines that target, target those certain hormones, that’s why one medicine can work in a bunch of different spaces. It really is important to highlight that, weight management. Heart disease, liver issues, diabetes… there are so many hormones that are shared and that’s why those medications are shared in those different spaces. And that’s what we want from a drug we want it to be impactful for as many things as possible. That’s why you see things like semaglutide; it goes by the brand names Ozempic and Wegovy. That’s why we see it being used for lots of different things because there are these shared hormones with different disease states and that’s why we get benefit across the board in a lot of these different areas.
RK: And you mentioned Ozempic or Wegovy, which is semaglutide some others just to round out the class might include dulaglutide or trulicity or loraglutide or victosa or succenda. These are medications, like you mentioned some are approved for diabetes and some are approved at the higher doses for obesity. A question that I often get asked is when you use these medications for obesity, any of the medications that you’ve talked about, whether GLP ones or the other medications that you talked about, how long do you continue on them? And what happens when you stop? Do you regain that weight?
ML: With medications for weight management, I typically frame these as chronic use medicine. Medicines that you’re going to be on long term because obesity is a chronic metabolic disease, and I view it just like Type 2 diabetes or hypertension. We use hypertension, for example, some folks will, follow the lowest salt diet you can even think about. But there are other things in their family history, their genetics that just predispose them to having a higher blood pressure they need a blood pressure medicine to manage that; to couple with their lifestyle efforts. That makes things better. And if down the line, we take the medicine away, what’s going to happen? Their blood pressure is going to go back up because those underlying things that we can’t control, like their genetic factors are still there with weight management, it’s important to think about the chronic metabolic disease definition and center the way that we use medications in that space. They really are meant to be used long term. Not to say that can’t go off of them, down the line, you absolutely can, but you need to be working with a weight management specialist to do that. The one thing that I think gets confusing in the current cultural conversation around these newer medicines in particular, is that there is a concern that if I stop this medicine, is there a rebound effect?
Am I more susceptible to weight regain because of something that the medicine is doing. And the short answer to that is no, it really is about understanding what things are contributing to weight gain in the first place and are they still there? For someone with polycystic ovarian syndrome, that’s something they’re going to have for a while.
So using a medicine to help control that will help manage their weight. And if you go off of that, Weight management medicine than the weight gain that comes with polycystic ovarian syndrome will come back So it is more nuanced in that way, for someone who has Insomnia someone who is under chronic stress for someone who had like all of the etiologies those causes of weight gain that we Talked about before if those things are still there. They will continue to contribute to weight gain I think a really important example of this is those who are on medicines that cause weight gain, and they need to be on them. Insulin is one example, but there are many others. There are certain cancer medications that cause weight gain, and we of course need to continue those.
There are mental health medications that folks need to be on, and they cause weight gain, but they need to continue them. When that’s the case, a weight loss medicine is critical because the thing that’s going on in the background that caused weight to go up in the first place is still there. There’s nothing inherently about the weight loss medicine that creates this rebound effect. It’s just about understanding what affects weight gain. And if those factors are still present, you take the medicine away. Weight will come back on for those reasons. It’s a little bit subtle and nuanced, but yes long-term medicines for most of these is typically the way that I use them.
RK: It makes sense that you really do have to address the underlying factors contributing to why you’re gaining weight in the first place. And you mentioned that the newer agents, particularly are really ones that can be used chronically especially if there are underlying factors.
But as I understand that the stimulants are really designed to be used just for a few months at a time. Is that right? Some of the older medicines?
ML: That’s a state-by-state question. When you’re a provider, it’s important to know the laws of your state, because the evidence supports long term use of stimulants like Phentermine, but in some states, it is still only approved for short term use. And by short term use, I mean three months or less. There is a discrepancy by what is supported by the literature and what is still listed in FDA guidelines and how the states interpret those things. All of that is to say, we can absolutely safely use the stimulant medications long term. Guidelines support that use, but that isn’t always possible depending on where you live. That all said. It’s important to be closely monitored when you’re on any of these medications because we want to make sure that you’re safe and supported while you’re on these drugs. It’s important to monitor blood pressure and heart rate and things like that. A good example of the long-term use. Phentermine, for example, is in one of those combination pills we talked about, Qsymia, that’s approved for long term use. It really just is about the way that the medications are labeled at the federal and the state level. My feeling about this is that the current labeling guidelines are not necessarily up to date with the current science of weight loss. My hope is that the labeling catches up to that. But that is where that confusion point comes from. I use these medicines long term in my practice, provided that, folks meet criteria to do that safely, but that will vary significantly state to state, depending on what those state laws are.
RK: That’s really good to know thanks for going over that. We didn’t have the chance to really go into the side effects of some of these newer medications like the GLP 1s. I think that the GI side effects and also the cost tend to be limiting factors on an individual basis something also to keep in mind.
Lastly, I think we probably don’t need to go into great detail about surgery, but I wonder if you could briefly talk about whom you might consider for surgery if the lifestyle changes, and the, and the medical management isn’t achieving the desired goals.
ML: Sure, the surgical guidelines have actually changed, and I can highlight that evolution and who is eligible for bariatric surgery it used to be that folks would need to have a BMI of 40 or greater or 35 or greater plus a weight related disorder like diabetes like hypertension.
The new guidelines say that bariatric surgery should be considered for those with a BMI of 30 to 35 class one obesity and in folks who have that BMI, but have not achieved significant or durable weight loss or a comorbidity improvement with non-surgical methods like lifestyle management or pharmacotherapy medications. And then for everyone who has a BMI of 35 or greater with or without a weight associated comorbidity, they would also be eligible there is basically this shift downward by five BMI points.
It’s important to note that while these guidelines have recently been updated, and I think that it’s great to be able to offer surgery to folks who would benefit from it, not all insurance companies have quite adopted this new guideline statement. For that reason, not all surgeons are offering bariatric surgery at those lower BMI thresholds. But in time, that will be the new standard. Right now, we typically will talk about surgery with those old cutoffs, 40 or above, or 35 and above with a weight associated comorbidity. If someone has really difficult to manage diabetes, for example, and their BMI is 32, and their insurance will cover a bariatric procedure, we absolutely will talk about that. Because we’re in this transition space of guidelines, it really does require talking to each individual person and saying, ” what are your health goals? Is this something that you really want to consider at a lower BMI threshold? Is insurance going to cover it? Is it affordable for you?” it’s important to make sure that we address that. All of those things Surgery is a wonderful tool, with the sleeve gastrectomy, which is, one of the more common procedures you can expect to lose 20 to 25 percent of body weight with the gastric bypass or the Roux-en-Y, so to speak 30 to 40%. With diabetes, if we’re talking about that specific example, we can get remission. of diabetes with surgery, 29 percent of those who have a bypass and 23 percent of those who have a sleeve. All that is to say they’re very effective. When we’re looking at how surgery intersects with the evolving landscape of medications, it is actually very exciting because some of the new drugs that we’re using for diabetes and for weight loss are approaching how effective surgery is.
I think that that is going to continue to happen. That we have medicines that are valuable in a similar way to bariatric surgery somebody would qualify by newer guidelines, but their insurance won’t cover it, then, they’re an incredible candidate for some of the, the stronger anti-obesity like some of the newer generation injection drugs that we were talking about.
RK: I agree. It’ll be interesting to see in the years to come how some of our medications may approach the outcomes that we see with surgery and remission, like you mentioned for diabetes. It’s something that we may not have talked about a few decades ago, and to think that surgery or even some of the medications that we have now could lead to remission of diabetes, not having diabetes at all anymore is pretty amazing, in some people that that could be seen. Of course, with any surgery, there are potential procedural complications that we need to be aware about, but in general, in the hands of an expert it can be done safely particularly in, in huge surgery centers. Absolutely.
As we round out our conversation today and thank you so much for taking the time to talk with us about this important topic, I was wondering what you would say to a person who’s listening today who might be struggling with their weight loss goals and really feeling discouraged in terms of what they’ve been able to accomplish.
How do you counsel your patients who are beginning or are struggling with their weight loss journey in terms of what they can attain and what is feasible in the short and long term.
ML: The first thing that I’ll say is that this is hard. We’ve been talking a lot about this complex conversation with metabolism hormones. It can get really deep when we talk about what causes weight management challenges and, makes them more difficult to kind of manage over time. It’s really important to understand the complexity of all of this and how much it sometimes feels like folks who are struggling are at odds with their hormones.
They’re sort of fighting it. against them in a way, ” Hey, my body’s not really doing what I wanted to do. What’s going on?” This is a really complex disorder. It is absolutely manageable with a healthcare partner who, can really kind of help you navigate what has been the key contributor to weight gain, and then we can understand how to provide support going forward. It is difficult. This is a lifelong journey for so many folks who are not alone. For those reasons, it’s important to seek out expert care so that we can understand, is there another medical condition that’s contributing? Is there a medication that you’re taking that’s making this a little bit harder? Are there lifestyle habits that we can give support around? Are there other medical conditions that we can help manage? Just think through your lifelong journey and know that you’re not alone in this. There are absolutely folks who it is our job. It is our pleasure to help. That is what we are here to do. And there are so many ways that we can help with weight management and help with long-term sustainable weight loss for the providers out there, I think it’s important to really listen to folks, listen to the lifestyle journey. I learned so much from my patients just sort of asking, can you walk me through your journey. That can tell me so much. Then once I understand your journey, that’s when I can understand, how do I begin to provide support? How do we begin to help make weight management a little bit more approachable and how can I give you support long-term and give you back your quality of life? Seeking health care support from an expert I think is truly important just because it’s really complex as we’ve been talking through. We as providers are here to offer compassion and supportive guidance, never judgment. That is a key takeaway for my practice.
RK: Well, thank you so much, Dr. Laudenslager, for being here today, for sharing your expert perspectives on weight management and obesity, specifically in diabetes and the non-judgmental compassionate care that’s so important for long term success and the different options that individuals have in terms of managing and approaching challenges with weight management. Thank you again for being here today.
ML: It’s been such a pleasure. Thank you for having me.
RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.
For more information, visit hopkinsdiabetesinfo.org. We love to hear from our listeners. The email address is hopkinsdiabetesinfo@jhmi.edu. Thanks for listening. Be well and see you next time.
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- Home - | - Episode 35: Diabetes and ObesityIn Episode 35, Dr. Kalyani welcomes Marci Laudenslager, MD MHS DABOM. Dr. Laudenslager is an internal medicine and obesity medicine physician in the Johns Hopkins Healthful Eating, Activity & Weight Program. She is a Diplomate of the American Board of Obesity Medicine and her clinical expertise is in obesity and obesity-associated disorders. She was recognized as a “Top Weight Management Doctor” by Baltimore Magazine in 2021, 2022, and 2023. Dr. Laudenslager is a clinician educator and researcher – her work is specifically focused on the educational gap that exists in obesity medicine. She teaches learners at all levels of medical training and designs curricula aimed at improving obesity medical education. Dr. Laudenslager received her doctor of medicine degree from Drexel University College of Medicine. She completed her internal medicine residency at the Hoftra Northwell Internal Medicine Residency Program where she additionally served as Chief Resident. She became a Harvard Macy Scholar during her year as Chief Resident. Dr. Laudenslager received her Master of Health Science degree from The Johns Hopkins Bloomberg School of Public Health and completed her General Internal Medicine Fellowship training at The Johns Hopkins University School of Medicine.
TranscriptEPISODE 34: DIABETES & STROKE
Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani at Johns Hopkins. We developed this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts please visit hopkinsdiabetesinfo.org.
Today, we are pleased to speak with board certified cerebrovascular neurologist, Dr. Michelle Johansen, who will be speaking to us about diabetes and stroke. Dr. Johansen is an associate professor of neurology at the Johns Hopkins University School of Medicine and associate faculty in the Bloomberg School of Public Health. Dr. Johansen focuses her research on the heart brain connection, specifically with regard to stroke etiology in order to allow earlier diagnosis and ultimately prevention of embolic stroke. Dr. Johansen has already established a relationship between cardiac markers of health and brain changes in her patients at Johns Hopkins, as well as large community-based population studies. She also has been recognized for her work in understanding the vascular contributions to impaired cognition in patients with heart disease. She’s the inaugural Guy McCann associate professor of neurology. Welcome Dr. Johansen.
Michelle Johansen, MD, PhD: Hi Rita. Thank you so much for having me.
RK: We are so excited to have you on the podcast today. I wondered if you could start off by just telling us what is a stroke and what are the different types of strokes? .
MJ: Sure, I’m glad that you started with this question because a lot of people know a lot about disease states, for example, a heart attack. if you went out on the street in Baltimore and you said, “What’s a heart attack?” most people would be able to describe to you in some form or another what a heart attack is. But a lot of people struggle with a stroke. And even when we do a great job educating our patients after they’ve had a stroke, when they come back to see us in clinics, sometimes they’re still not sure what a stroke is.
A stroke is normally thought of as, “cessation of blood flow to a specific part of the brain for a period of time.” That’s the simplest way to think about it. That can happen as a result of a clot that embolizes and goes to the brain and causes stroke, most commonly being a cardiombolic stroke, and that’s the area that I do research in.
It can come from some of the very small blood vessels of the brain that get damaged over time. For example, in diabetes, those are small vessel strokes are called lacunar disease; that’s another type of stroke. It can come from plaque that builds up in the carotid artery, for example, and that can break loose and go to the brain.
That’s an example of a large artery stroke. Those are the big three buckets. Then we have strokes that are called cryptogenic strokes where we’re not quite sure of the cause. And there have been other subsets that have come out from that, for example, “ASSUS” -symbolic stroke of unknown source, you can have strokes that are in the venous system.
So, you can have clots in the veins of the brain and that can lead to a venous stroke. You can have dissections, which are tears in the blood vessel wall. Those can lead to strokes. You can have strokes in the setting of cancer or infection. These are the different, some of the simple big buckets that we think about stroke, but not all stroke is the same, and that’s why it’s really important to figure out what caused the stroke.
RK: Wow, it seems like there’s so many different, kinds of strokes and different ways that blood flow to the brain can really be affected and contribute to a stroke. How common are strokes in the general population?
MJ: Sure, we talked a lot about ischemic stroke and I’m focusing on ischemic stroke because this is for patients who have diabetes and ischemic stroke is the most common type of stroke for people who have diabetes.
But there’s also bleeding types of strokes. For example, hemorrhagic strokes are where people have brain bleeds. You can have subarachnoid hemorrhage, which is where you have rupture of an aneurysm and that results in blood in the brain.
We’re very proud of the fact that in the United States now stroke is the fifth leading cause of death. It used to be much higher than that, but across the world globally, stroke is still the second leading cause of death, but is a huge, massive public health problem and normally falls right behind cardiac disease across the world. And then here in the States, now it’s below accidental trauma and some other types of deaths.
But stroke is a massive problem and there’s certain things that we can do about it to prevent a stroke, particularly within a certain period of time after someone has acute onset of stroke symptoms. If they get themselves to an emergency room, there’s things that we can do about it in a very acute period of time.
RK: It sounds like, it’s quite common, unfortunately, as a source of early death or morbidity in many parts of the world. And though it’s gotten better in the United States, it sounds like it’s still one of the top five causes. How is stroke related to diabetes? I feel like we talk a lot about diabetes and heart disease and cardiovascular risk factors. How do strokes relate to the risk of cardiovascular disease in people with diabetes?
MJ: Yeah, I think it’s a continuum. I think that you can think about diabetes causing cardiovascular risk, what’s in results in stroke. But I think you can also think about diabetes probably having a direct mechanism besides just vascular risk that leads to damage to those small blood vessels in the brain.
As you know, diabetes is a complex disease and diabetes is associated with lots of other vascular risk problems and normally come in pairs like high blood pressure. People who have diabetes are, tend to have higher rates of obesity certainly have higher rates of heart failure, those sorts of things.
And all of those can cause strokes, but. There has been data to suggest that those high glucose states that diabetics experience are not good for the structures of the brain. Diabetes in and of itself, even though it’s paired with those other risk factors, is known to be an independent risk factor for stroke.
And that’s through that high glucose concentration, it’s not good for anything. And that includes the blood vessels and structures of the brain. When we do PET scans looking for cancer, people usually ignore the brain. And the reason for that is because PET scans use glucose or a glucose-based tracer, and the brain is constantly running on glucose.
It takes it up. It’s important to think about what that high state of glucose throughout your body is doing, particularly when you’re thinking about stroke and stroke risk factors.
RK: What I recall, glucose is a very important energy source in the brain. Is it not?
MJ: That’s exactly right. that’s why when you’re doing scans of the brain, you can certainly use PET for the brain. Absolutely. But my point being that glucose is such a high energy source and your brain is constantly drawing energy. That’s why it’s so sensitive to perturbations or loss of oxygen. You can restart somebody’s heart. You can transplant a kidney, but for the brain within seconds, when you have clots or whatever else is causing lack of blood flow to the brain, you have instantaneous damage and instantaneous dying of brain parenchymal tissue.
RK: Sounds like all the more reason to really notice the symptoms promptly given how acutely or how suddenly these symptoms can occur.
Just before we move on to talking a little bit more about treatment, you talked about risk factors such as high blood glucose, which clearly in people with diabetes, we work to lower, to individualize targets, to reduce many complications. And it sounds like for stroke as well, really keeping the glucose at target can, can really help reduce the risk of adverse impacts on the brain.
What other cardiovascular risk factors can contribute to stroke in people with diabetes? How about high blood pressure and high cholesterol?
MJ: Yeah, Rita, that’s a podcast in and of itself. And there have been books and papers and I mean, we could fill my whole office with research in this area. The very short answer to that question is that absolutely – yes.
So high blood pressure can cause stroke, obesity, like I already said. If you are doing behavioral things that led to the diabetes in the first place, if you are drinking alcohol, if you are eating too much fatty foods, therefore leading to high cholesterol, if you, and then also high triglycerides, if you have lack of physical activity, all of those things that I’m sure you’ve talked about before on your podcast that are cardiovascular risk factors or risk factors for stroke.
RK: And how much more common are strokes in people with diabetes versus without diabetes?
MJ: the proportion of patients who have strokes are certainly higher among those that have cardiovascular risk. And because diabetes is so tightly linked to cardiovascular risk, then we know that stroke is much higher among people who have diabetes compared to those that don’t.
Like you said, pulling out the absolute, increase risk for someone who has diabetes is a little tricky because it’s obviously dependent on the patient who’s sitting in front of you. And a lot of those risk factors go together. You talk about metabolic syndrome in the field of diabetes all the time, but we know that the proportion of patients who have, for example, lacunar artery disease and have lacunar strokes, almost all of them have diabetes. Very specific to some stroke mechanisms, but just globally with regards to stroke, diabetes, patients who have diabetes, much, much higher risk of having a stroke compared to those who do not.
RK: Yeah, we definitely talk about the higher risk of the micro- and macrovascular complications as we talk about complications in the small blood vessels and then the large blood vessels of the body and certainly just like the heart, the brain is one.
We probably don’t screen for as well as we should in our own primary practices or even in our endocrine practices, but certainly one that can cause, as you said, suddenly acute morbidity and acute symptoms as well. Are there certain locations in the brain you talked about lacunar strokes for those who may not be familiar with what part of the brain that is? I wonder if you could talk about whether there are certain parts of the brain where people with diabetes may be more likely to have strokes.
MJ: Yeah, I would honestly say that probably all parts of the brain are open for discussion for someone with diabetes and the reason for that is because, it depends on the risk and the contribution of the risk to the patient sitting in front of you.
MJ: Diabetes is associated with lots of things. If someone has diabetes, and they also smoke and are obese, then chances of having damage to the small blood vessels of the brain, which are deep structures, are higher. As a result of that, you can get strokes in the brainstem, and you can get strokes in those deep structures in the brain, and they usually control motor function on one side of the body and sensory function on one side of the body.
They’re referred to as pure motor strokes or pure sensory strokes. That’s a very simplified overview of that. Patients with diabetes, however, can also have other things that can cause strokes. Patients with diabetes can have poor cardiac function, which can predispose them to atrial fibrillation. They can end up with a cardioembolic stroke just like anybody else.
Patients who have diabetes can have high cholesterol, eat the wrong kinds of foods, which is what led to the diabetes in the first place, and also smoke and then end up with plaque in the carotid artery and have a large artery stroke. That’s why stroke is not just cut and dry. It’s not because someone has diabetes, they’re going to have this kind of stroke. It all interplays together. But if you want to think about lacunar, those small vessel disease strokes, which patients with diabetes certainly have a high risk for those, would tend to affect the deeper structures of the brain and or the brainstem. And the brainstem is important for cranial nerves. It’s important for the way your eyes move, for example, your swallowing capability. All of those important structures are in the brainstem. Even though the blood vessels themselves may be small and feed a smaller area of the brain, those strokes can also be very devastating.
RK: Wow. That’s so interesting to hear about how many different parts of the brain can be affected.
And then also those deep brain, that the brainstem strokes that you talked about too, that are much more common in people with diabetes. Talking now about the signs and symptoms of stroke, what should a person with diabetes be aware of as a warning sign for a stroke?
MJ: There are the warning signs and symptoms of stroke all localized to the area of the brain that the patient is having the stroke. If you have a stroke going on and the part of the brain that is responsible for your speech, then you’re going to have a condition called aphasia where you have problems with your language.
If you’re having stroke in the part of the brain that controls your face, then you’re going to have weakness on the contralateral or opposite side normally, if it involves a cortex or ipsilateral side, if it involves the brainstem, which is the same side of the face. All of those things are how we localize the lesion, which is what we teach our neurology residents to do, which means a patient is sitting in front of you, if you’re a good neurologist, you should be able to do a physical exam and tell me exactly where that stroke is happening.
Because if you use your physical exam and do a good neuro exam, we can figure it out, which is unbelievable, and one of the reasons why I love neurology so much. If we’re thinking about specific to patients who have diabetes. The signs and symptoms that I teach for stroke are the signs and symptoms that everybody should know.
There’s a little mnemonic that I use. It’s called BE FAST. And the emphasis there is on time. As soon as you notice anything that’s not quite right, you don’t want to sit around and wait. Now people say the lines at the emergency room are horrible. I understand that. But if you say the word stroke, they will quickly get you to an evaluation because they realize once again, there are things we can do within a short period of time.
So what are those signs and symptoms? If you have weakness of one side of your body, your face and your arm particularly, can also involve your leg. If you have lack of sensation on one side of your body, face, arm, and leg. If you have difficulty getting your words out. If you have sudden loss of vision, particularly part of your vision, and it’s in the same side of your vision in both eyes, That is concerning for stroke, or if you have loss of only vision in one eye, that’s concerning for stroke.
If you have balance problems, meaning all of a sudden it was like you got hit by a train and you can no longer walk, that’s concerning for stroke. If you have difficulty getting up out of a chair, you feel so profoundly dizzy, you have a headache, you have nausea, vomiting, unlike anything you’ve ever experienced before.
That’s concerning for stroke. that’s a way that we think about signs and symptoms of stroke. And it’s also involvement of those cranial nerves like I talked about before. Stroke is pretty hard to miss. Normally what people think is, “Oh, I just hope that it would get better.” They have weakness on one side and just something is wrong, but I just hope that it would get better. And that’s where the delays come in getting treatments.
RK: That’s really interesting. Some of the signs and symptoms you described. It could happen with other conditions as well, but it’s that suddenness, it sounds like, of the symptoms and signs and the fact that it doesn’t go away, the numbness like you talked about.
MJ: Certainly things can present like a stroke, but stroke is different in that it normally only involves one side of the body. If you have spinal cord problems and you have back problems, you’re going to have weakness in both of your legs. If you have some sort of neuropathy problem, you’re going to have numbness and tingling, carpal tunnel, usually involving both of your wrists from typing, for example.
Stroke is unique in that it normally lateralizes only to one side. There’s very few things that cause you to have weakness in one side of your face and one arm. That’s pretty distinctive of stroke. Especially if you’re not sure, get evaluated because people will be able to figure it out if you’re having a stroke or not. And even if they’re not sure. The things that we do for you are normally very safe in people who have stroke mimics. Let’s say you have a horrible headache, but you have a history of migraines. It’s unlike your typical migraine. You’re seeing things in your vision. You’re not quite sure what’s going on. Get evaluated because if we do something like give you an IV thrombolytic, which is a very strong blood thinner we can give to patients within a certain amount of time after the onset of symptoms, normally those patients are fine, even if it does turn out to be a migraine.
RK: That’s really helpful to have that tip that it’s the unilaterality or the asymmetry really on the one side that is a real big tip off that it could be a stroke and that, even if it’s a mimic, like you said, it’s a migraine or something else that the treatments are relatively safe, even just to be assured that it’s not a stroke and to present to the emergency room. Among people with diabetes, are there certain individuals that are at higher risk of stroke, for instance, longer duration of diabetes people who have higher blood sugars or A1C or, for instance, I saw a person in my clinic just the other day who came in with a very high blood pressure that she had not known 190 over 130. And we started talking about the symptoms of stroke to be aware of just with that high level, what, what are the risk factors among people with diabetes who would be at higher risk for stroke?
MJ: In general, like we talked about before, if people who have diabetes are more likely to develop heart disease, as a result of that, that would make them higher risk. There’s been literature to show that the more vascular risk factors that you have, they kind of stack on top of each other, the higher your overall risk of stroke. And some of those risk factors act together and they sort of have a kindling effect, which I’m sure you’ve educated your diabetic patients about a lot. The connection between diabetes and stroke obviously relates to how your body handles glucose. Clearly somebody who is a raging diabetic, poorly controlled, that patient is going to have much more risk of having damage to blood vessel structures because the body cannot keep up with that glucose that’s floating around in the body.
In order to kind of think about how you would lower your risk of stroke, in general, you would want your A1c to be lower. Patients who have lower A1c’s normally is going to have a lower average blood glucose for the past however many months. That’s a good thing. Blood pressure for patients who have diabetes should be absolutely normal intensive, less than that 140 over 90 and even that target has started moving down.
Cholesterol should be well controlled for patients who have diabetes. Nobody should be smoking. That doesn’t matter if you’re a diabetic or not. Thinking through all those things that we normally recommend for patients just to prevent stroke anyway, are the things that you would absolutely emphasize for somebody who has diabetes.
RK: Are there any differences across different sexes, men versus women, across different ethnicities, or even age? Is it only in older age that we’d see strokes, or could it occur at any age?
MJ: yes, yes, and yes, once again, that’s a whole topic in and of itself. Patients who are older age are normally at higher risk because age is an indicator of risk.
The older you get, the more likely you are to be on multiple medications, the more likely you are to not be meeting your exercise target, the more likely you are to have gained some weight, the more likely you are to have multiple vascular risk factors just as a result of being older. But we know that while age is a good moniker for how healthy someone is, that we always see the exceptions to the rule.
You have your patient who comes to clinic who’s 42 years old who looks like they’re 80 and you have your 80 year old who comes to clinic who acts like they’re 30. Age is just sort of a moniker for risk. Risk is what really matters. Men and women do vary, with regards to the way that you think about vascular risk, meaning some risk factors track more with women. Unfortunately, there are more women who are obese than men. But that doesn’t necessarily mean that men or women are at higher risk of stroke. We do know that more women are living with stroke, but we also know that more women live longer. There’s a lot of research going on in estrogen and how that contributes to stroke. We know that when women who are supplemented with estrogen, that hormone replacement therapy, we stopped doing that because that increased risk for cardiovascular disease and stroke. There’s a lot of research going on in that area about how hormones, et cetera, modify stroke risk. But in general, regardless of whether or not you’re a man or a woman, your signs and symptoms of stroke are pretty much going to be the same. Now, sometimes women have more subtle signs and symptoms, but those are the same signs and symptoms you should know for stroke. Stroke is no respecter of persons. It does not matter what race you are. There are some conditions that march along with race. For example, just like we talk about sickle cell being predominantly in African Americans or in people of African ancestry. Obviously that’s a unique risk factor for stroke, just like someone who’s from Northern European ancestry. We can have inheritable genetic diseases that predispose us to having stretchy blood vessels. Sometimes disease states march along with race, but stroke is no respecter of persons. While there may be some differences between things just based on risk factors, it doesn’t matter who you are or where you’re from. You can have all the money in the world and have a stroke. You can have no money in the world and have a stroke, and that’s why it’s such an important disease to recognize.
RK: That’s really important to emphasize and thank you for going through that. Really anyone, it sounds like with diabetes, could be at a higher risk for stroke. Understanding the factors that can increase your risk are important, but really it could impact anyone of any background.
If a patient goes to the emergency room with concerns of a stroke, maybe signs and symptoms that they or a family member noticed that seem concerning for a stroke, what are usually the next steps for diagnosing stroke? What kind of tests are done? And then what are the usual treatments that are done in the hospital?
MJ: That question has three parts. if you want to invite me back three more times, we can talk through them in appropriate detail, but if you have any doubts go to an emergency room and they will treat you according to your symptoms.
So once again, as a neurologist, you should not have to need an image. You should not have to have any additional tests. You should be able to make a clinical diagnosis of stroke based on the patient sitting in front of you. That’s what we always did for years and years before we got super fancy and started MRI’ing everybody.
I just gave a lecture this morning to a wonderful group of neurologists in Zambia. They do not have the resources that we have in the United States and in Europe. They have to figure these things out clinically. The first thing that should happen if you arrive to an emergency room is they should quickly say, Oh, you’re looking like a stroke. And you should have a rapid evaluation, either by an emergency room physician or an internal medicine physician or neurologist, and they will activate an alert. That alert says all hands on deck. People come running from everywhere to do very quick evaluations of you to see what your signs and symptoms are.
If you meet certain criteria on a score that says this is looking like a stroke, We’re automatically going to start talking to you about treatment, even before we do any of the tests, because once again, it’s a clinical diagnosis. Frequently you’ll get a head CT, which is a CAT scan. That’s a rapid evaluation to make sure there’s no blood in the brain. That would be a contraindication or an exclusion from me administering an IV medication that is a clot busting medication either called IV tissue plasminogen activator, or now we have a newer one called tenecteplase that will bust up clots in the brain and enable blood flow to be restored to the brain.
There are certain things that we rapidly evaluate for. Are you on a blood thinner? If you’re on a blood thinner, I can’t give you another blood thinner. Do you have blood in the brain? That’s a contraindication. Have you had recent major surgery that if you were to bleed from that site would be catastrophic? There’s a whole list of things that we go through. Are your platelets zero? those things we always evaluate for, but we don’t rely on an image or a test to say, “aha, you have stroke.” Once again, it is a clinical diagnosis. After we sort of go through a rapid evaluation to decide whether or not we’re going to treat you with a thrombolytic, then we start looking at the blood vessels. We look at the blood vessels because, there are procedures now called thrombectomies, or mechanical thrombectomies, where there is a guide wire and a wire that you can see using x ray technology, using an angiogram is what we call it, where you can thread this wire up through an artery in the groin or going into the radial artery in your wrist. We can go all the way up into the brain and we can actually pull the clot out. If I give you a medication that’s a clot busting medication, the clot does not resolve, your symptoms are not getting better. Or even if I can’t give you that clot busting medication, you still may be eligible for this procedure. It really started coming to fruition around 2015 and it has exploded now. We have even more research supporting how efficacious this procedure is. And once again, we can only do it for certain patients within a certain time window. The reason time matters so much for stroke. is because if the brain dies off, that brain becomes a nasty wet sponge, which means it is very sensitive to perturbations in blood flow and it likes to bleed and the tissue is damaged, beyond repair. Your body is constantly trying to save the brain. The brain is the number one organ that your body is trying to save. But once it goes past a certain point, your body can’t do anything to save it anymore. That’s why time really matters and why these procedures we can only do to a certain point, because past that point we may actually cause more harm than good.
If there’s already irreparable tissue damage in the brain, and I go up with a catheter to retrieve a clot, that could actually cause more problems. All of these things are rapidly evaluated when you come to an emergency room. And then after that acute period is over, then do we start looking and doing more testing for what’s going on with your heart, what’s going on with your blood profile, have you been ill, and all those other things. That happens after that acute time period, because we recognize , as clinicians, that there’s a time period that if you miss it, it’s gone.
RK: That’s neat to hear about all the newer ways to really treat a stroke and also the thrombolytics as well, and all the options that are available if presenting or coming to the hospital in a timely manner, when you say that time is important, are we talking about minutes? Are we talking about hours? Could you give us a sense of that window knowing that it might vary?
MJ: Every minute counts, literally every minute counts because we have shown that neurons die in minutes. Now, when we’re talking about treatment windows, standard treatment window for giving an IV thrombolytic is about three hours. In certain patients, we can go out to four and a half hours and then pass out; I can’t give you a thrombolytic anymore. For the thrombectomy procedure, we can now go out to even about 24 hours after the onset of symptom, but I do not recommend that. The faster you get to me, the better your outcomes are for both the thrombolytic and the thrombectomy procedure.
RK: That’s really important for our audience to hear that really every minute counts. I liked how you summarize that, that even though some of these procedures can be done within a few hours for even up to a day, it sounds like the sooner the better. And getting to the hospital is the most important thing. After someone has been treated for a stroke, clearly it depends on when they presented and where the stroke is and how big the stroke is. But what is the recovery like? Do most people can even make the statement to most people recover from strokes or what does the long term outlook look like?
MJ: That is a hard question to answer with a generic statement, because like you said, it is a stroke by stroke. Literally every single patient, it depends. It depends on how much stroke burden there is, meaning how big the stroke is. The bigger the stroke, the worse you do. It depends on what structures of the brain were involved. Some of them have other areas of the brain that can also do that function. Some of them, there’s only one area of the brain that does that function.
And if it’s damaged, it’s much harder to recuperate from. Things like motor recovery, while it can be absolutely devastating, you can work on walking and you can work on using your arm again and the assist device that we have for those types of things are better than someone who can’t talk. If you’re cognitively impaired as a result of a stroke, that impacts everything, including your motor recovery.
And the burden from that stroke may be a tiny little lesion, but it may hit an area of the brain. That’s imperative for the way that you think and process and make decisions. I would argue that even though that stroke burden is not large, they may look okay, if they’re impaired and cannot talk to you, that’s pretty devastating.
RK: Yeah, for sure. To affect an area of the brain that impacts speaking or impacts walking, those are major parts of our day to day quality of life. Do people recover function ever?
MJ: A hundred percent. I’m a big believer in neuroplasticity. I’m a big believer in rehabilitation. There are lots of people doing rehab. I work here at Johns Hopkins and we have lots of neat research things that are going on, constantly trying to get people to a state of a hundred percent. Most patients never reach a hundred percent, but they can get pretty darn close. They can get 99. 999 percent there. And they’ll come to you and say, Hey, Dr. Johansson, when I’m tired and sick, I don’t feel like myself again. Some of my stroke symptoms start coming out. But no one would guess in a million years that they’ve ever had a stroke. Absolutely, people do recover completely from a stroke. But once again, it depends on the severity, it depends on how big the stroke was, and it depends their vascular risk factors.
If you know someone who is otherwise completely healthy and runs and just happens to have atrial fibrillation, they’re going to do much better. And a diabetic who’s obese, who has a large waist circumference, who’s smoking, chewing tobacco, high triglycerides, that patient is not going to recover as well.
RK: Well, it’s really encouraging to hear about the possibility for recovery and the ability of the neurons , to grow again, to grow back, to do the function they did before, but again, on a case by case basis, it sounds like in terms of the ability for functional recovery, but still encouraging that that is possible. When we talk about prevention, when we take a step back now and we talk about how can we prevent strokes, and you already talked about, the cardiovascular risk factors, the high blood pressure, the cholesterol, the smoking, really getting those at target, not smoking at all. What about lifestyle such as diet and exercise? We talk about that all the time for people with diabetes. How does that impact the risk of stroke?
MJ: Oh, 100%. I am a huge believer in that. When patients come to see me, I love stroke and I love stroke neurology for a couple of reasons. I love the acuity of it. I love taking care of really sick patients. I love taking care of patients in an ICU, but I also love the long term aspects and counseling of it. I love seeing patients back in clinic that I’ve seen for years and years and years and, asking me how I’m doing and how things are going and getting to hear their stories. Partnering with people to set goals is something that I try to do on a pretty regular basis. In other words, thinking about how you can set specific goals that are measurable and attainable and realistic and have a time component to them, that S.M.A.R.T. Goal acronym, is really imperative in patients who’ve had strokes because these are things that they have established. These are habits that are incredibly hard to break. Smoking is one of the most addictive habits that we know. And now they are maybe even devastated from a stroke and slightly depressed. We know depression increases after stroke. And now I’m going to come to them and say, quit smoking, which is the one thing that gives them comfort during a day. That’s incredibly challenging. that goes to really partnering with your patient. Giving them hope, never false hope, but hope that they can actually make a decision and change meaningfully and then emphasizing what the American Heart Association, what the American Stroke Association recommends. At least 30 minutes, five days a week of cardiovascular exercise. We are all busy, but it does not matter how busy you are. You can find 30 minutes in your day to get up and move around, to get your heart rate up, and those sorts of things are imperative. Small changes to diet, you may not be able to lose 50 pounds in two weeks, but you can say this week I am going to try to only have one soda this whole week. That’s my goal for this week. And then the next week you can say, I’m going to try to not have any sodas at all next week. And then the week after that, you can say, well, I didn’t, I actually didn’t even really miss those sodas. I feel better now because I got rid of some of the caffeine. This week I am going to try to fill in the blank.
So small little pieces to sort of lead them to these goals. Because if you say, “Don’t smoke, maintain a healthy diet, exercise every day, limit alcohol, learn to manage stress.” I love it that we just throw these things at patients and they walk out, “oh my gosh, how am I going to do this?” We know from trying to make changes ourselves. I’m trying to make a change and do something more productive with the amount of time that I have. I have written that out. I have put it in my phone. I have an alert set for me, right, to remind me that this is something that I am trying to do on a daily basis. if I have to do that with something small, these are things that have been going on for years for patients. Counseling is imperative, as well as emphasizing how imperative it is for their health. This is not just, well, quit smoking because you should. Quit smoking because you have to, you’ve already had a stroke, your risk of having another one is higher.
RK: Yeah, it’s so true. I think all those things you mentioned, all the different factors that can contribute to stroke, it can be overwhelming to think about them all together, but if you break it down to small steps that are attainable on a week by week basis, you can see incremental gains over time. That’s so important. And it sounds like the lifestyle modifications, which we recommend for diabetes in general, particularly apply if you will, for stroke as well, in terms of reducing the stroke risk. I wonder if you could comment on any specific medications for diabetes that might’ve been found either to increase risk or decrease risk in stroke. For instance, I, have come across studies that have looked at pioglitazone or Actos. I’m not sure if that’s something that you could comment on, but from what I recall, that they may have protective effects in diabetes. Could you comment on specific medications?
MJ: Sure, no, I’m happy to. You probably know a lot more of the recent literature regarding some of the newer agents that are coming out. Obviously, I’m seeing a lot more patients who are getting placed on GLP-1 RA such as Ozempic (semaglutide) who are trying to lose weight. So, in general, I think the easy answer is the better control of your diabetes, the lower your stroke risk is going to be. I am not aware of any medications that are used for diabetes that increase stroke risk. That’s excellent news. Patients who have hemoglobin A1c lowering on some of the newer agents as well as the ability to lose weight, for example with Ozempic, all of those things are going to help them get to where they need to be to lower their stroke risk; we’re all on board with that. We work very closely with our endocrinologists at Hopkins to really have a conversation about what’s going on. And I appreciate that because sometimes those medications may help my stroke patients get to their goals.
I know there’s a lot of discussion about who should be on these agents, allocation of agents, resource, et cetera. And as time goes on, as time goes on, there’s going to be a lot more data out about what these agents look like for stroke prevention. I anticipate a time when a lot more people are going to be on these types of agents.
Other medications that we use, good old aspirin, still works. Aspirin is wonderful when it comes to secondary prevention of stroke, meaning you’ve had a stroke, then therefore you’re on an aspirin. We use other antiplatelet drugs like Clopidogrel, which is Plavix, Brilinta (ticagrelor), there’s other drugs that we use that are antiplatelet drugs in particular cases. We are big fans, I am particularly a big fan of statins and the power of statins. Some of the newer lowering agents that are coming out are also very helpful for getting patients cholesterols to where they need to be. And then finally, anticoagulation if there’s an indication- Apixaban, Rivaroxaban, Dabigatran, Edoxaban even Coumadin. All of those things may be useful given the specific etiology of the stroke, for example, an atrial fibrillation to decrease risk going forward. Once again, all depending on the mechanism and the patient sitting in front of you.
RK: That’s encouraging to hear of the role that some pharmacotherapies can have as well, and as you talked about the newer treatments, the SGLT2 class of medications and the GLP1 receptor agonist class, specific agents in those classes that have demonstrated benefits in reducing heart attacks and stroke, but I think it is true that they’re probably all lumped together in those studies looking specifically at stroke as an outcome. We probably do need more data, I would think. Would you agree?
MJ: Oh yeah, absolutely. I know I was just at the scientific sessions, which is a big cardiology conference, giving a talk. And some of the drug reps were there and they were talking about how there are trials that are going to come out, looking at some of these agents specifically with regards to stroke risk. Like you said, stroke, unfortunately, in my view, gets lumped in with a lot of other cardiac endpoints. But it’s really nice when they focus numbers on stroke because sometimes we don’t have enough numbers of patients who have strokes in those populations to get to meaningful outcomes. But looking at some of those drugs in the future going forward, particularly with regards to stroke risk, is going to be very interesting.
RK: Yeah, I agree. And thanks for talking about aspirin. Sometimes old is best and definitely in people with a history of heart disease or stroke or peripheral vascular disease to be on aspirin. What are your thoughts on aspirin as a primary prevention of people who haven’t had a history of stroke to reduce the risk?
MJ: Right now, unless you have another indication, okay, and lots of people with diabetes have other indications. But if we’re just talking about a purist person. Who doesn’t have another indication for aspirin for primary prevention of stroke, there is no evidence. It used to be everybody got thrown on an aspirin and we realized that the risk of bleeding was too high for primary prevention of stroke.
So I’m talking about someone who has had a stroke and also has diabetes, then absolutely aspirin would be indicated in that person. There’s some maybe literature coming out about how aspirin might help with cognition in older people. All of that is very soft yet. For primary prevention, there’s no evidence for aspirin. For secondary prevention, meaning they’ve had a stroke, then we do advocate for aspirin.
RK: Yeah, definitely that risk of bleeding that you can see with aspirin, especially in older ages, I think in the studies have been found to be one of the harms, if you will, of using aspirin as prevention in terms of hemorrhagic stroke, having bleeding in the brain. So it’s interesting how much our practices have changed over time from really giving aspirin to many people to now narrowing it to a very specific population of people at higher risk. Of, of stroke and heart disease. What about low blood glucose? Can that put people at risk for stroke?
MJ: Normally hypoglycemia is not thought of as a contributor to stroke. I will say that patients who are hypoglycemic can mimic having a stroke. If you have hypoglycemia, you can get behavioral changes. You can be sort of loopy and out of it. Your speech can sound slurred. You may have a sort of loss of consciousness and a fall that could be attributed to a stroke. Hypoglycemia can be considered a stroke mimic.
But once again, if I treat someone who has low blood glucose by accident, let’s say now everybody has. finger stick point of care glucose testing in the emergency room, you get an answer in seconds. Chances of me giving a thrombolytic to someone who only has hypoglycemia is pretty rare, but even if I do do it, once again, I’ve told you that the literature supports that patients who have stroke mimics like hypoglycemia, if we think they’re having a stroke and we give them a thrombolytic, they normally do just fine. So you should still go to the emergency room.
RK: Well, that’s definitely reassuring. Dr. Johansen, it’s been so great to hear all about strokes and prevention and treatment and people with diabetes. I wonder if you have some parting words for our listeners who are concerned about the risk of stroke. What would you say to them in terms of the top things they can do today?
MJ: Obviously the point of this podcast is not to terrify anybody. We don’t want to say that just because you have diabetes, you’re going to have a stroke tomorrow. That’s not the goal here. But the goal is to think about stroke as a condition that you never want to get to. If you have an opportunity to do a better job of controlling your diabetes today, to prevent a stroke in the future, use stroke as a motivating factor. That would be the first thing I would say. The second thing is know the signs and symptoms of stroke, just as we’ve already discussed on the podcast. And then the third thing is be your own advocate. If you’re not feeling well and there’s something going on, tell somebody right away, that way you can get help right away. Sometimes, I hear so many patients who say, “Oh, well I thought it was my diabetic neuropathy.” No, no. If there’s something that’s completely different than what you’ve experienced before, then you should act on that and take that seriously. And come in and be evaluated, because worst case scenario, we turn you away and say you haven’t had a stroke. And I would say that’s actually a good outcome.
RK: Dr. Johansen, thank you so much for sharing your expertise and really underscoring the importance of being aware of the signs and symptoms and alerting those around you and seeking immediate help. It sounds like they’re definitely preventable, but having the knowledge is imperative to prevention. So, thank you so much for being here with us today.
MJ: All right. Thank you so much.
RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives. For more information, visit hopkinsdiabetesinfo.org. Thanks for listening, be well, and see you next time.
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- Home - | - Episode 34: Diabetes and StrokeIn Episode 34, we welcome board certified cerebrovascular neurologist, Dr. Michelle Johansson, who will be speaking to us about diabetes and stroke. Dr. Johansson is an Associate Professor of Neurology at the Johns Hopkins University School of Medicine and Associate Faculty in the Bloomberg School of Public Health. Dr. Johansson focuses her research on the heart brain connection, specifically with regard to stroke etiology in order to allow earlier diagnosis and ultimately prevention of embolic stroke. Dr. Johansson has already established a relationship between cardiac markers of health and brain changes in her patients at Johns Hopkins, as well as large community-based population studies. She also has been recognized for her work in understanding the vascular contributions to impaired cognition in patients with heart disease.
TranscriptEPISODE 34: DIABETES & STROKE
Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani at Johns Hopkins. We developed this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts please visit hopkinsdiabetesinfo.org.
Today, we are pleased to speak with board certified cerebrovascular neurologist, Dr. Michelle Johansson, who will be speaking to us about diabetes and stroke. Dr. Johansson is an associate professor of neurology at the Johns Hopkins University School of Medicine and associate faculty in the Bloomberg School of Public Health. Dr. Johansson focuses her research on the heart brain connection, specifically with regard to stroke etiology in order to allow earlier diagnosis and ultimately prevention of embolic stroke. Dr. Johansson has already established a relationship between cardiac markers of health and brain changes in her patients at Johns Hopkins, as well as large community-based population studies. She also has been recognized for her work in understanding the vascular contributions to impaired cognition in patients with heart disease. She’s the inaugural Guy McCann associate professor of neurology. Welcome Dr. Johansson.
Michelle Johansen, MD, PhD: Hi Rita. Thank you so much for having me.
RK: We are so excited to have you on the podcast today. I wondered if you could start off by just telling us what is a stroke and what are the different types of strokes? .
MJ: Sure, I’m glad that you started with this question because a lot of people know a lot about disease states, for example, a heart attack. if you went out on the street in Baltimore and you said, “What’s a heart attack?” most people would be able to describe to you in some form or another what a heart attack is. But a lot of people struggle with a stroke. And even when we do a great job educating our patients after they’ve had a stroke, when they come back to see us in clinics, sometimes they’re still not sure what a stroke is.
A stroke is normally thought of as, “cessation of blood flow to a specific part of the brain for a period of time.” That’s the simplest way to think about it. That can happen as a result of a clot that embolizes and goes to the brain and causes stroke, most commonly being a cardiombolic stroke, and that’s the area that I do research in.
It can come from some of the very small blood vessels of the brain that get damaged over time. For example, in diabetes, those are small vessel strokes are called lacunar disease; that’s another type of stroke. It can come from plaque that builds up in the carotid artery, for example, and that can break loose and go to the brain.
That’s an example of a large artery stroke. Those are the big three buckets. Then we have strokes that are called cryptogenic strokes where we’re not quite sure of the cause. And there have been other subsets that have come out from that, for example, “ASSUS” -symbolic stroke of unknown source, you can have strokes that are in the venous system.
So, you can have clots in the veins of the brain and that can lead to a venous stroke. You can have dissections, which are tears in the blood vessel wall. Those can lead to strokes. You can have strokes in the setting of cancer or infection. These are the different, some of the simple big buckets that we think about stroke, but not all stroke is the same, and that’s why it’s really important to figure out what caused the stroke.
RK: Wow, it seems like there’s so many different, kinds of strokes and different ways that blood flow to the brain can really be affected and contribute to a stroke. How common are strokes in the general population?
MJ: Sure, we talked a lot about ischemic stroke and I’m focusing on ischemic stroke because this is for patients who have diabetes and ischemic stroke is the most common type of stroke for people who have diabetes.
But there’s also bleeding types of strokes. For example, hemorrhagic strokes are where people have brain bleeds. You can have subarachnoid hemorrhage, which is where you have rupture of an aneurysm and that results in blood in the brain.
We’re very proud of the fact that in the United States now stroke is the fifth leading cause of death. It used to be much higher than that, but across the world globally, stroke is still the second leading cause of death, but is a huge, massive public health problem and normally falls right behind cardiac disease across the world. And then here in the States, now it’s below accidental trauma and some other types of deaths.
But stroke is a massive problem and there’s certain things that we can do about it to prevent a stroke, particularly within a certain period of time after someone has acute onset of stroke symptoms. If they get themselves to an emergency room, there’s things that we can do about it in a very acute period of time.
RK: It sounds like, it’s quite common, unfortunately, as a source of early death or morbidity in many parts of the world. And though it’s gotten better in the United States, it sounds like it’s still one of the top five causes. How is stroke related to diabetes? I feel like we talk a lot about diabetes and heart disease and cardiovascular risk factors. How do strokes relate to the risk of cardiovascular disease in people with diabetes?
MJ: Yeah, I think it’s a continuum. I think that you can think about diabetes causing cardiovascular risk, what’s in results in stroke. But I think you can also think about diabetes probably having a direct mechanism besides just vascular risk that leads to damage to those small blood vessels in the brain.
As you know, diabetes is a complex disease and diabetes is associated with lots of other vascular risk problems and normally come in pairs like high blood pressure. People who have diabetes are, tend to have higher rates of obesity certainly have higher rates of heart failure, those sorts of things.
And all of those can cause strokes, but. There has been data to suggest that those high glucose states that diabetics experience are not good for the structures of the brain. Diabetes in and of itself, even though it’s paired with those other risk factors, is known to be an independent risk factor for stroke.
And that’s through that high glucose concentration, it’s not good for anything. And that includes the blood vessels and structures of the brain. When we do PET scans looking for cancer, people usually ignore the brain. And the reason for that is because PET scans use glucose or a glucose-based tracer, and the brain is constantly running on glucose.
It takes it up. It’s important to think about what that high state of glucose throughout your body is doing, particularly when you’re thinking about stroke and stroke risk factors.
RK: What I recall, glucose is a very important energy source in the brain. Is it not?
MJ: That’s exactly right. that’s why when you’re doing scans of the brain, you can certainly use PET for the brain. Absolutely. But my point being that glucose is such a high energy source and your brain is constantly drawing energy. That’s why it’s so sensitive to perturbations or loss of oxygen. You can restart somebody’s heart. You can transplant a kidney, but for the brain within seconds, when you have clots or whatever else is causing lack of blood flow to the brain, you have instantaneous damage and instantaneous dying of brain parenchymal tissue.
RK: Sounds like all the more reason to really notice the symptoms promptly given how acutely or how suddenly these symptoms can occur.
Just before we move on to talking a little bit more about treatment, you talked about risk factors such as high blood glucose, which clearly in people with diabetes, we work to lower, to individualize targets, to reduce many complications. And it sounds like for stroke as well, really keeping the glucose at target can, can really help reduce the risk of adverse impacts on the brain.
What other cardiovascular risk factors can contribute to stroke in people with diabetes? How about high blood pressure and high cholesterol?
MJ: Yeah, Rita, that’s a podcast in and of itself. And there have been books and papers and I mean, we could fill my whole office with research in this area. The very short answer to that question is that absolutely – yes.
So high blood pressure can cause stroke, obesity, like I already said. If you are doing behavioral things that led to the diabetes in the first place, if you are drinking alcohol, if you are eating too much fatty foods, therefore leading to high cholesterol, if you, and then also high triglycerides, if you have lack of physical activity, all of those things that I’m sure you’ve talked about before on your podcast that are cardiovascular risk factors or risk factors for stroke.
RK: And how much more common are strokes in people with diabetes versus without diabetes?
MJ: the proportion of patients who have strokes are certainly higher among those that have cardiovascular risk. And because diabetes is so tightly linked to cardiovascular risk, then we know that stroke is much higher among people who have diabetes compared to those that don’t.
Like you said, pulling out the absolute, increase risk for someone who has diabetes is a little tricky because it’s obviously dependent on the patient who’s sitting in front of you. And a lot of those risk factors go together. You talk about metabolic syndrome in the field of diabetes all the time, but we know that the proportion of patients who have, for example, lacunar artery disease and have lacunar strokes, almost all of them have diabetes. Very specific to some stroke mechanisms, but just globally with regards to stroke, diabetes, patients who have diabetes, much, much higher risk of having a stroke compared to those who do not.
RK: Yeah, we definitely talk about the higher risk of the micro- and macrobioscopic complications as we talk about complications in the small blood vessels and then the large blood vessels of the body and certainly just like the heart, the brain is one.
We probably don’t screen for as well as we should in our own primary practices or even in our endocrine practices, but certainly one that can cause, as you said, suddenly acute morbidity and acute symptoms as well. Are there certain locations in the brain you talked about lacunar strokes for those who may not be familiar with what part of the brain that is? I wonder if you could talk about whether there are certain parts of the brain where people with diabetes may be more likely to have strokes.
MJ: Yeah, I would honestly say that probably all parts of the brain are open for discussion for someone with diabetes and the reason for that is because, it depends on the risk and the contribution of the risk to the patient sitting in front of you.
MJ: Diabetes is associated with lots of things. If someone has diabetes, and they also smoke and are obese, then chances of having damage to the small blood vessels of the brain, which are deep structures, are higher. As a result of that, you can get strokes in the brainstem, and you can get strokes in those deep structures in the brain, and they usually control motor function on one side of the body and sensory function on one side of the body.
They’re referred to as pure motor strokes or pure sensory strokes. That’s a very simplified overview of that. Patients with diabetes, however, can also have other things that can cause strokes. Patients with diabetes can have poor cardiac function, which can predispose them to atrial fibrillation. They can end up with a cardioembolic stroke just like anybody else.
Patients who have diabetes can have high cholesterol, eat the wrong kinds of foods, which is what led to the diabetes in the first place, and also smoke and then end up with plaque in the carotid artery and have a large artery stroke. That’s why stroke is not just cut and dry. It’s not because someone has diabetes, they’re going to have this kind of stroke. It all interplays together. But if you want to think about lacunar, those small vessel disease strokes, which patients with diabetes certainly have a high risk for those, would tend to affect the deeper structures of the brain and or the brainstem. And the brainstem is important for cranial nerves. It’s important for the way your eyes move, for example, your swallowing capability. All of those important structures are in the brainstem. Even though the blood vessels themselves may be small and feed a smaller area of the brain, those strokes can also be very devastating.
RK: Wow. That’s so interesting to hear about how many different parts of the brain can be affected.
And then also those deep brain, that the brainstem strokes that you talked about too, that are much more common in people with diabetes. Talking now about the signs and symptoms of stroke, what should a person with diabetes be aware of as a warning sign for a stroke?
MJ: There are the warning signs and symptoms of stroke all localized to the area of the brain that the patient is having the stroke. If you have a stroke going on and the part of the brain that is responsible for your speech, then you’re going to have a condition called aphasia where you have problems with your language.
If you’re having stroke in the part of the brain that controls your face, then you’re going to have weakness on the contralateral or opposite side normally, if it involves a cortex or ipsilateral side, if it involves the brainstem, which is the same side of the face. All of those things are how we localize the lesion, which is what we teach our neurology residents to do, which means a patient is sitting in front of you, if you’re a good neurologist, you should be able to do a physical exam and tell me exactly where that stroke is happening.
Because if you use your physical exam and do a good neuro exam, we can figure it out, which is unbelievable, and one of the reasons why I love neurology so much. If we’re thinking about specific to patients who have diabetes. The signs and symptoms that I teach for stroke are the signs and symptoms that everybody should know.
There’s a little mnemonic that I use. It’s called BE FAST. And the emphasis there is on time. As soon as you notice anything that’s not quite right, you don’t want to sit around and wait. Now people say the lines at the emergency room are horrible. I understand that. But if you say the word stroke, they will quickly get you to an evaluation because they realize once again, there are things we can do within a short period of time.
So what are those signs and symptoms? If you have weakness of one side of your body, your face and your arm particularly, can also involve your leg. If you have lack of sensation on one side of your body, face, arm, and leg. If you have difficulty getting your words out. If you have sudden loss of vision, particularly part of your vision, and it’s in the same side of your vision in both eyes, That is concerning for stroke, or if you have loss of only vision in one eye, that’s concerning for stroke.
If you have balance problems, meaning all of a sudden it was like you got hit by a train and you can no longer walk, that’s concerning for stroke. If you have difficulty getting up out of a chair, you feel so profoundly dizzy, you have a headache, you have nausea, vomiting, unlike anything you’ve ever experienced before.
That’s concerning for stroke. that’s a way that we think about signs and symptoms of stroke. And it’s also involvement of those cranial nerves like I talked about before. Stroke is pretty hard to miss. Normally what people think is, “Oh, I just hope that it would get better.” They have weakness on one side and just something is wrong, but I just hope that it would get better. And that’s where the delays come in getting treatments.
RK: That’s really interesting. Some of the signs and symptoms you described. It could happen with other conditions as well, but it’s that suddenness, it sounds like, of the symptoms and signs and the fact that it doesn’t go away, the numbness like you talked about.
MJ: Certainly things can present like a stroke, but stroke is different in that it normally only involves one side of the body. If you have spinal cord problems and you have back problems, you’re going to have weakness in both of your legs. If you have some sort of neuropathy problem, you’re going to have numbness and tingling, carpal tunnel, usually involving both of your wrists from typing, for example.
Stroke is unique in that it normally lateralizes only to one side. There’s very few things that cause you to have weakness in one side of your face and one arm. That’s pretty distinctive of stroke. Especially if you’re not sure, get evaluated because people will be able to figure it out if you’re having a stroke or not. And even if they’re not sure. The things that we do for you are normally very safe in people who have stroke mimics. Let’s say you have a horrible headache, but you have a history of migraines. It’s unlike your typical migraine. You’re seeing things in your vision. You’re not quite sure what’s going on. Get evaluated because if we do something like give you an IV thrombolytic, which is a very strong blood thinner we can give to patients within a certain amount of time after the onset of symptoms, normally those patients are fine, even if it does turn out to be a migraine.
RK: That’s really helpful to have that tip that it’s the unilaterality or the asymmetry really on the one side that is a real big tip off that it could be a stroke and that, even if it’s a mimic, like you said, it’s a migraine or something else that the treatments are relatively safe, even just to be assured that it’s not a stroke and to present to the emergency room. Among people with diabetes, are there certain individuals that are at higher risk of stroke, for instance, longer duration of diabetes people who have higher blood sugars or A1C or, for instance, I saw a person in my clinic just the other day who came in with a very high blood pressure that she had not known 190 over 130. And we started talking about the symptoms of stroke to be aware of just with that high level, what, what are the risk factors among people with diabetes who would be at higher risk for stroke?
MJ: In general, like we talked about before, if people who have diabetes are more likely to develop heart disease, as a result of that, that would make them higher risk. There’s been literature to show that the more vascular risk factors that you have, they kind of stack on top of each other, the higher your overall risk of stroke. And some of those risk factors act together and they sort of have a kindling effect, which I’m sure you’ve educated your diabetic patients about a lot. The connection between diabetes and stroke obviously relates to how your body handles glucose. Clearly somebody who is a raging diabetic, poorly controlled, that patient is going to have much more risk of having damage to blood vessel structures because the body cannot keep up with that glucose that’s floating around in the body.
In order to kind of think about how you would lower your risk of stroke, in general, you would want your A1c to be lower. Patients who have lower A1c’s normally is going to have a lower average blood glucose for the past however many months. That’s a good thing. Blood pressure for patients who have diabetes should be absolutely normal intensive, less than that 140 over 90 and even that target has started moving down.
Cholesterol should be well controlled for patients who have diabetes. Nobody should be smoking. That doesn’t matter if you’re a diabetic or not. Thinking through all those things that we normally recommend for patients just to prevent stroke anyway, are the things that you would absolutely emphasize for somebody who has diabetes.
RK: Are there any differences across different sexes, men versus women, across different ethnicities, or even age? Is it only in older age that we’d see strokes, or could it occur at any age?
MJ: yes, yes, and yes, once again, that’s a whole topic in and of itself. Patients who are older age are normally at higher risk because age is an indicator of risk.
The older you get, the more likely you are to be on multiple medications, the more likely you are to not be meeting your exercise target, the more likely you are to have gained some weight, the more likely you are to have multiple vascular risk factors just as a result of being older. But we know that while age is a good moniker for how healthy someone is, that we always see the exceptions to the rule.
You have your patient who comes to clinic who’s 42 years old who looks like they’re 80 and you have your 80 year old who comes to clinic who acts like they’re 30. Age is just sort of a moniker for risk. Risk is what really matters. Men and women do vary, with regards to the way that you think about vascular risk, meaning some risk factors track more with women. Unfortunately, there are more women who are obese than men. But that doesn’t necessarily mean that men or women are at higher risk of stroke. We do know that more women are living with stroke, but we also know that more women live longer. There’s a lot of research going on in estrogen and how that contributes to stroke. We know that when women who are supplemented with estrogen, that hormone replacement therapy, we stopped doing that because that increased risk for cardiovascular disease and stroke. There’s a lot of research going on in that area about how hormones, et cetera, modify stroke risk. But in general, regardless of whether or not you’re a man or a woman, your signs and symptoms of stroke are pretty much going to be the same. Now, sometimes women have more subtle signs and symptoms, but those are the same signs and symptoms you should know for stroke. Stroke is no respecter of persons. It does not matter what race you are. There are some conditions that march along with race. For example, just like we talk about sickle cell being predominantly in African Americans or in people of African ancestry. Obviously that’s a unique risk factor for stroke, just like someone who’s from Northern European ancestry. We can have inheritable genetic diseases that predispose us to having stretchy blood vessels. Sometimes disease states march along with race, but stroke is no respecter of persons. While there may be some differences between things just based on risk factors, it doesn’t matter who you are or where you’re from. You can have all the money in the world and have a stroke. You can have no money in the world and have a stroke, and that’s why it’s such an important disease to recognize.
RK: That’s really important to emphasize and thank you for going through that. Really anyone, it sounds like with diabetes, could be at a higher risk for stroke. Understanding the factors that can increase your risk are important, but really it could impact anyone of any background.
If a patient goes to the emergency room with concerns of a stroke, maybe signs and symptoms that they or a family member noticed that seem concerning for a stroke, what are usually the next steps for diagnosing stroke? What kind of tests are done? And then what are the usual treatments that are done in the hospital?
MJ: That question has three parts. if you want to invite me back three more times, we can talk through them in appropriate detail, but if you have any doubts go to an emergency room and they will treat you according to your symptoms.
So once again, as a neurologist, you should not have to need an image. You should not have to have any additional tests. You should be able to make a clinical diagnosis of stroke based on the patient sitting in front of you. That’s what we always did for years and years before we got super fancy and started MRI ing everybody.
I just gave a lecture this morning to a wonderful group of neurologists in Zambia. They do not have the resources that we have in the United States and in Europe. They have to figure these things out clinically. The first thing that should happen if you arrive to an emergency room is they should quickly say, Oh, you’re looking like a stroke. And you should have a rapid evaluation, either by an emergency room physician or an internal medicine physician or neurologist, and they will activate an alert. That alert says all hands on deck. People come running from everywhere to do very quick evaluations of you to see what your signs and symptoms are.
If you meet certain criteria on a score that says this is looking like a stroke, We’re automatically going to start talking to you about treatment, even before we do any of the tests, because once again, it’s a clinical diagnosis. Frequently you’ll get a head CT, which is a CAT scan. That’s a rapid evaluation to make sure there’s no blood in the brain. That would be a contraindication or an exclusion from me administering an IV medication that is a clot busting medication either called IV tissue plasminogen activase, or now we have a newer one called tenecteplase that will bust up clots in the brain and enable blood flow to be restored to the brain.
There are certain things that we rapidly evaluate for. Are you on a blood thinner? If you’re on a blood thinner, I can’t give you another blood thinner. Do you have blood in the brain? That’s a contraindication. Have you had recent major surgery that if you were to bleed from that site would be catastrophic? There’s a whole list of things that we go through. Are your platelets zero? those things we always evaluate for, but we don’t rely on an image or a test to say, “aha, you have stroke.” Once again, it is a clinical diagnosis. After we sort of go through a rapid evaluation to decide whether or not we’re going to treat you with a thrombolytic, then we start looking at the blood vessels. We look at the blood vessels because, there are procedures now called thrombectomies, or mechanical thrombectomies, where there is a guide wire and a wire that you can see using x ray technology, using an angiogram is what we call it, where you can thread this wire up through an artery in the groin or going into the radial artery in your wrist. We can go all the way up into the brain and we can actually pull the clot out. If I give you a medication that’s a clot busting medication, the clot does not resolve, your symptoms are not getting better. Or even if I can’t give you that clot busting medication, you still may be eligible for this procedure. It really started coming to fruition around 2015 and it has exploded now. We have even more research supporting how efficacious this procedure is. And once again, we can only do it for certain patients within a certain time window. The reason time matters so much for stroke. is because if the brain dies off, that brain becomes a nasty wet sponge, which means it is very sensitive to perturbations in blood flow and it likes to bleed and the tissue is damaged, beyond repair. Your body is constantly trying to save the brain. The brain is the number one organ that your body is trying to save. But once it goes past a certain point, your body can’t do anything to save it anymore. That’s why time really matters and why these procedures we can only do to a certain point, because past that point we may actually cause more harm than good.
If there’s already irreparable tissue damage in the brain, and I go up with a catheter to retrieve a clot, that could actually cause more problems. All of these things are rapidly evaluated when you come to an emergency room. And then after that acute period is over, then do we start looking and doing more testing for what’s going on with your heart, what’s going on with your blood profile, have you been ill, and all those other things. That happens after that acute time period, because we recognize , as clinicians, that there’s a time period that if you miss it, it’s gone.
RK: That’s neat to hear about all the newer ways to really treat a stroke and also the thrombolytics as well, and all the options that are available if presenting or coming to the hospital in a timely manner, when you say that time is important, are we talking about minutes? Are we talking about hours? Could you give us a sense of that window knowing that it might vary?
MJ: Every minute counts, literally every minute counts because we have shown that neurons die in minutes. Now, when we’re talking about treatment windows, standard treatment window for giving an IV thrombolytic is about three hours. In certain patients, we can go out to four and a half hours and then pass out; I can’t give you a thrombolytic anymore. For the thrombectomy procedure, we can now go out to even about 24 hours after the onset of symptom, but I do not recommend that. The faster you get to me, the better your outcomes are for both the thrombolytic and the thrombectomy procedure.
RK: That’s really important for our audience to hear that really every minute counts. I liked how you summarize that, that even though some of these procedures can be done within a few hours for even up to a day, it sounds like the sooner the better. And getting to the hospital is the most important thing. After someone has been treated for a stroke, clearly it depends on when they presented and where the stroke is and how big the stroke is. But what is the recovery like? Do most people can even make the statement to most people recover from strokes or what does the long term outlook look like?
MJ: That is a hard question to answer with a generic statement, because like you said, it is a stroke by stroke. Literally every single patient, it depends. It depends on how much stroke burden there is, meaning how big the stroke is. The bigger the stroke, the worse you do. It depends on what structures of the brain were involved. Some of them have other areas of the brain that can also do that function. Some of them, there’s only one area of the brain that does that function.
And if it’s damaged, it’s much harder to recuperate from. Things like motor recovery, while it can be absolutely devastating, you can work on walking and you can work on using your arm again and the assist device that we have for those types of things are better than someone who can’t talk. If you’re cognitively impaired as a result of a stroke, that impacts everything, including your motor recovery.
And the burden from that stroke may be a tiny little lesion, but it may hit an area of the brain. That’s imperative for the way that you think and process and make decisions. I would argue that even though that stroke burden is not large, they may look okay, if they’re impaired and cannot talk to you, that’s pretty devastating.
RK: Yeah, for sure. To affect an area of the brain that impacts speaking or impacts walking, those are major parts of our day to day quality of life. Do people recover function ever?
MJ: A hundred percent. I’m a big believer in neuroplasticity. I’m a big believer in rehabilitation. There are lots of people doing rehab. I work here at Johns Hopkins and we have lots of neat research things that are going on, constantly trying to get people to a state of a hundred percent. Most patients never reach a hundred percent, but they can get pretty darn close. They can get 99. 999 percent there. And they’ll come to you and say, Hey, Dr. Johansson, when I’m tired and sick, I don’t feel like myself again. Some of my stroke symptoms start coming out. But no one would guess in a million years that they’ve ever had a stroke. Absolutely, people do recover completely from a stroke. But once again, it depends on the severity, it depends on how big the stroke was, and it depends their vascular risk factors.
If you know someone who is otherwise completely healthy and runs and just happens to have atrial fibrillation, they’re going to do much better. And a diabetic who’s obese, who has a large waist circumference, who’s smoking, chewing tobacco, high triglycerides, that patient is not going to recover as well.
RK: Well, it’s really encouraging to hear about the possibility for recovery and the ability of the neurons , to grow again, to grow back, to do the function they did before, but again, on a case by case basis, it sounds like in terms of the ability for functional recovery, but still encouraging that that is possible. When we talk about prevention, when we take a step back now and we talk about how can we prevent strokes, and you already talked about, the cardiovascular risk factors, the high blood pressure, the cholesterol, the smoking, really getting those at target, not smoking at all. What about lifestyle such as diet and exercise? We talk about that all the time for people with diabetes. How does that impact the risk of stroke?
MJ: Oh, 100%. I am a huge believer in that. When patients come to see me, I love stroke and I love stroke neurology for a couple of reasons. I love the acuity of it. I love taking care of really sick patients. I love taking care of patients in an ICU, but I also love the long term aspects and counseling of it. I love seeing patients back in clinic that I’ve seen for years and years and years and, asking me how I’m doing and how things are going and getting to hear their stories. Partnering with people to set goals is something that I try to do on a pretty regular basis. In other words, thinking about how you can set specific goals that are measurable and attainable and realistic and have a time component to them, that S.M.A.R.T. Goal acronym, is really imperative in patients who’ve had strokes because these are things that they have established. These are habits that are incredibly hard to break. Smoking is one of the most addictive habits that we know. And now they are maybe even devastated from a stroke and slightly depressed. We know depression increases after stroke. And now I’m going to come to them and say, quit smoking, which is the one thing that gives them comfort during a day. That’s incredibly challenging. that goes to really partnering with your patient. Giving them hope, never false hope, but hope that they can actually make a decision and change meaningfully and then emphasizing what the American Heart Association, what the American Stroke Association recommends. At least 30 minutes, five days a week of cardiovascular exercise. We are all busy, but it does not matter how busy you are. You can find 30 minutes in your day to get up and move around, to get your heart rate up, and those sorts of things are imperative. Small changes to diet, you may not be able to lose 50 pounds in two weeks, but you can say this week I am going to try to only have one soda this whole week. That’s my goal for this week. And then the next week you can say, I’m going to try to not have any sodas at all next week. And then the week after that, you can say, well, I didn’t, I actually didn’t even really miss those sodas. I feel better now because I got rid of some of the caffeine. This week I am going to try to fill in the blank.
So small little pieces to sort of lead them to these goals. Because if you say, “Don’t smoke, maintain a healthy diet, exercise every day, limit alcohol, learn to manage stress.” I love it that we just throw these things at patients and they walk out, “oh my gosh, how am I going to do this?” We know from trying to make changes ourselves. I’m trying to make a change and do something more productive with the amount of time that I have. I have written that out. I have put it in my phone. I have an alert set for me, right, to remind me that this is something that I am trying to do on a daily basis. if I have to do that with something small, these are things that have been going on for years for patients. Counseling is imperative, as well as emphasizing how imperative it is for their health. This is not just, well, quit smoking because you should. Quit smoking because you have to, you’ve already had a stroke, your risk of having another one is higher.
RK: Yeah, it’s so true. I think all those things you mentioned, all the different factors that can contribute to stroke, it can be overwhelming to think about them all together, but if you break it down to small steps that are attainable on a week by week basis, you can see incremental gains over time. That’s so important. And it sounds like the lifestyle modifications, which we recommend for diabetes in general, particularly apply if you will, for stroke as well, in terms of reducing the stroke risk. I wonder if you could comment on any specific medications for diabetes that might’ve been found either to increase risk or decrease risk in stroke. For instance, I, have come across studies that have looked at pioglitazone or Actos. I’m not sure if that’s something that you could comment on, but from what I recall, that they may have protective effects in diabetes. Could you comment on specific medications?
MJ: Sure, no, I’m happy to. You probably know a lot more of the recent literature regarding some of the newer agents that are coming out. Obviously, I’m seeing a lot more patients on Ozimbic who are getting placed on Ozimbic who are trying to lose weight. So, in general, I think the easy answer is the better control of your diabetes, the lower your stroke risk is going to be. I am not aware of any medications that are used for diabetes that increase stroke risk. That’s excellent news. Patients who have hemoglobin A1c lowering on some of the newer agents as well as the ability to lose weight, for example with Ozimbic, all of those things are going to help them get to where they need to be to lower their stroke risk; we’re all on board with that. We work very closely with our endocrinologists at Hopkins to really have a conversation about what’s going on. And I appreciate that because sometimes those medications may help my stroke patients get to their goals.
I know there’s a lot of discussion about who should be on these agents, allocation of agents, resource, et cetera. And as time goes on, as time goes on, there’s going to be a lot more data out about what these agents look like for stroke prevention. I anticipate a time when a lot more people are going to be on these types of agents.
Other medications that we use, good old aspirin, still works. Aspirin is wonderful when it comes to secondary prevention of stroke, meaning you’ve had a stroke, then therefore you’re on an aspirin. We use other antiplatelet drugs like Clopidogrel, which is Plavix, Rolenta, there’s other drugs that we use that are antiplatelet drugs in particular cases. We are big fans, I am particularly a big fan of statins and the power of statins. Some of the newer lowering agents that are coming out are also very helpful for getting patients cholesterols to where they need to be. And then finally, anticoagulation if there’s an indication- Apixaban, Rivaroxaban, Dabigatran, Edoxaban even Coumadin. All of those things may be useful given the specific etiology of the stroke, for example, an atrial fibrillation to decrease risk going forward. Once again, all depending on the mechanism and the patient sitting in front of you.
RK: That’s encouraging to hear of the role that some pharmacotherapies can have as well, and as you talked about the newer treatments, the SGLT2 class of medications and the GLP1 receptor agonist class, specific agents in those classes that have demonstrated benefits in reducing heart attacks and stroke, but I think it is true that they’re probably all lumped together in those studies looking specifically at stroke as an outcome. We probably do need more data, I would think. Would you agree?
MJ: Oh yeah, absolutely. I know I was just at the scientific sessions, which is a big cardiology conference, giving a talk. And some of the drug reps were there and they were talking about how there are trials that are going to come out, looking at some of these agents specifically with regards to stroke risk. Like you said, stroke, unfortunately, in my view, gets lumped in with a lot of other cardiac endpoints. But it’s really nice when they focus numbers on stroke because sometimes we don’t have enough numbers of patients who have strokes in those populations to get to meaningful outcomes. But looking at some of those drugs in the future going forward, particularly with regards to stroke risk, is going to be very interesting.
RK: Yeah, I agree. And thanks for talking about aspirin. Sometimes old is best and definitely in people with a history of heart disease or stroke or peripheral vascular disease to be on aspirin. What are your thoughts on aspirin as a primary prevention of people who haven’t had a history of stroke to reduce the risk?
MJ: Right now, unless you have another indication, okay, and lots of people with diabetes have other indications. But if we’re just talking about a purist person. Who doesn’t have another indication for aspirin for primary prevention of stroke, there is no evidence. It used to be everybody got thrown on an aspirin and we realized that the risk of bleeding was too high for primary prevention of stroke.
So I’m talking about someone who has had a stroke and also has diabetes, then absolutely aspirin would be indicated in that person. There’s some maybe literature coming out about how aspirin might help with cognition in older people. All of that is very soft yet. For primary prevention, there’s no evidence for aspirin. For secondary prevention, meaning they’ve had a stroke, then we do advocate for aspirin.
RK: Yeah, definitely that risk of bleeding that you can see with aspirin, especially in older ages, I think in the studies have been found to be one of the harms, if you will, of using aspirin as prevention in terms of hemorrhagic stroke, having bleeding in the brain. So it’s interesting how much our practices have changed over time from really giving aspirin to many people to now narrowing it to a very specific population of people at higher risk. Of, of stroke and heart disease. What about low blood glucose? Can that put people at risk for stroke?
MJ: Normally hypoglycemia is not thought of as a contributor to stroke. I will say that patients who are hypoglycemic can mimic having a stroke. If you have hypoglycemia, you can get behavioral changes. You can be sort of loopy and out of it. Your speech can sound slurred. You may have a sort of loss of consciousness and a fall that could be attributed to a stroke. Hypoglycemia can be considered a stroke mimic.
But once again, if I treat someone who has low blood glucose by accident, let’s say now everybody has. finger stick point of care glucose testing in the emergency room, you get an answer in seconds. Chances of me giving a thrombolytic to someone who only has hypoglycemia is pretty rare, but even if I do do it, once again, I’ve told you that the literature supports that patients who have stroke mimics like hypoglycemia, if we think they’re having a stroke and we give them a thrombolytic, they normally do just fine. So you should still go to the emergency room.
RK: Well, that’s definitely reassuring. Dr. Johanson, it’s been so great to hear all about strokes and prevention and treatment and people with diabetes. I wonder if you have some parting words for our listeners who are concerned about the risk of stroke. What would you say to them in terms of the top things they can do today?
MJ: Obviously the point of this podcast is not to terrify anybody. We don’t want to say that just because you have diabetes, you’re going to have a stroke tomorrow. That’s not the goal here. But the goal is to think about stroke as a condition that you never want to get to. If you have an opportunity to do a better job of controlling your diabetes today, to prevent a stroke in the future, use stroke as a motivating factor. That would be the first thing I would say. The second thing is know the signs and symptoms of stroke, just as we’ve already discussed on the podcast. And then the third thing is be your own advocate. If you’re not feeling well and there’s something going on, tell somebody right away, that way you can get help right away. Sometimes, I hear so many patients who say, “Oh, well I thought it was my diabetic neuropathy.” No, no. If there’s something that’s completely different than what you’ve experienced before, then you should act on that and take that seriously. And come in and be evaluated, because worst case scenario, we turn you away and say you haven’t had a stroke. And I would say that’s actually a good outcome.
RK: Dr. Johansson, thank you so much for sharing your expertise and really underscoring the importance of being aware of the signs and symptoms and alerting those around you and seeking immediate help. It sounds like they’re definitely preventable, but having the knowledge is imperative to prevention. So, thank you so much for being here with us today.
MJ: All right. Thank you so much.
RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives. For more information, visit hopkinsdiabetesinfo.org. Thanks for listening, be well, and see you next time.
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- Home - | - Episode 33: A Real Patient Story – Gestational DiabetesFor today’s podcast, Dr. Kalyani introduces Shweta, a person who has had gestational diabetes, who will be sharing her journey with gestational diabetes during her pregnancy and follow up afterwards. Dr. Kalyani also welcomes Dr. Wendy Bennett, an Associate Professor in the Division of General Internal Medicine, with Joint Appointments of the Johns Hopkins University, Bloomberg, School of Public Health, Departments of Population, Family and Reproductive Health and epidemiology. Dr. Bennett’s research focuses on obesity, prevention, and control. She is interested in behavioral interventions to promote healthy weight, gain in pregnancy and postpartum weight loss. She also has expertise in technological interventions for nutritional assessment and intervention delivery. She is a general internist and sees patients at Johns Hopkins, Bayview Medical Center. Lastly, Dr. Kalyani welcomes Christine McKinney, Senior nutritionist of the Johns Hopkins University School of Medicine. Christine is a Registered Dietician and Certified Diabetes Care and Education Specialist. She is working in research, focused on weight management and perinatal health. She previously worked at Johns Hopkins, Bayview Medical Center’s Ob clinic specializing in gestational diabetes.
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- Home - | - Episode 32: Diabetes, Pancreatitis & Pancreatic CancerOn today’s podcast Dr. Rita Kalyani welcomes Dr. Michael Goggins who will be speaking with us about pancreatitis and pancreatic cancer. Dr. Goggins is a Professor of Pathology, Medicine and Oncology at The Johns Hopkins University School of Medicine. He opened the Pancreatic Cancer Early Detection Research Laboratory in 1999. He is an Attending Physician and Gastroenterologist at Johns Hopkins Hospital, the Sol Goldman Professor of Pancreatic Cancer Research, and Director of Research in the Division of Gastroenterology and Hepatology. He is PI of the multicenter Cancer of the Pancreas Screening-5, or “CAPS5” study, supported by the NCI through the Pancreatic Cancer Detection Consortium. He is also the principal investigator of an R01 to support evaluating markers of early pancreatic cancer, a Johns Hopkins SPORE in Gastrointestinal Cancer investigator and co-PI of a Stand Up to Cancer Pancreatic Cancer Interception grant.
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- Home - | - Episode 31: Diabetes and SleepOn today’s podcast Dr. Rita Kalyani welcomes Dr. Jonathan Jun, who will be speaking with us about diabetes and sleep. Dr. Jun holds a pulmonary critical care and sleep medicine position at Johns Hopkins. He specializes in causes and consequences of obstructive sleep apnea and the interaction of sleep with metabolism. He received his medical degree from University of Maryland School of Medicine and completed his Internal Medicine Residency at Thomas Jefferson University Hospital. He did two fellowship programs at Johns Hopkins in Pulmonary and Critical Care, Medicine and Sleep Medicine. Dr. Jun now serves as an Associate Professor of Medicine in the Johns Hopkins Division of Pulmonary and Critical Care Medicine. He’s a member of the Sleep Fellowship program, evaluation and Clinical Competency Committee and provides teaching to medical students and residents at Johns Hopkins.
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- Home - | - Episode 30: PrediabetesOn today’s podcast, host Dr. Rita Kalyani welcomes Dr. Nes Mathioudakis, who will be speaking with us about prediabetes. Dr. Mathioudakis is an endocrinologist at Johns Hopkins focusing his clinical practice on the care of patients with endocrine disorders, with a particular clinical interest and research focus on diabetes. His research is focused on health informatics approaches for diabetes prevention and management. Dr. Mathioudakis received his medical degree from the Johns Hopkins University School of Medicine and completed his internal medicine residency at Johns Hopkins Bayview Medical Center. He did a fellowship in endocrinology, diabetes, and metabolism at the Johns Hopkins Hospital and then joined the faculty in the division in 2012. Dr. Mathioudakis also received his Masters of Health Science degree in Clinical Investigation. After receiving his master’s degree, he served as the clinical director of the Division of Endocrinology, Diabetes, & Metabolism from 2016 to 2021. Dr. Mathioudakis is currently an Associate Professor of Medicine at Johns Hopkins and the co-medical Director of the Baltimore Metropolitan Diabetes Regional Partnership, a five-year grant funded by the Maryland HSCRC to scale patient access to diabetes prevention programs and diabetes self-management training programs across the state.
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- Home - | - Episode 29: World Diabetes Day 2023For This year’s Special Edition Podcast for World Diabetes Day (Episode 29), Dr. Rita Kalyani welcomes Dr. Stanley Chen Cardenas to our podcast. Dr. Chen Cardenas is Assistant Professor of Medicine in the Division of Endocrinology, Diabetes, and Metabolism at the Johns Hopkins University School of Medicine. He was born in Panama, obtained his medical degree at the University of Panama, where he became interested in endocrinology and basic-translational research. This led him to migrate to the United States. He initially worked in an immunology lab in Panama, then at the Joslin Diabetes Center of Harvard Medical School where he studied microRNAs as biomarkers o beta cell destruction in type 1 DM. He continued his medical training in Baltimore at Sinai Hospital where he served as a Chief resident, followed by his endocrinology fellowship a Johns Hopkins University. While in residency and fellowship he worked on a murine model of obstructive sleep apnea studying how intermittent hypoxia and calcium channels impact glucose metabolism. He is currently interest is in adrenal gland disorders. Relevant for this podcast, as an endocrinologist he spent 2 years working in Latin America, more specifically in Panama, both in the public and private healthcare system. He recently published a book Chapter on Obesity and Metabolic Syndrome in Latin America.
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- Home - | - Episode 28: Diabetes and SmokingFor Podcast Episode 28, Dr. Rita Kalyani welcomes Dr. Panagis Galiatsatos to our podcast. Dr. Galiatsatos is an assistant professor and physician in the Johns Hopkins Division of Pulmonary Critical Care Medicine. He is Co-Chair of the Johns Hopkins Health Equity steering committee and, as a co-director and co-founder of Medicine for the Greater Good. He also serves as the director of the Tobacco Treatment Clinic at Johns Hopkins and has a particular interest and expertise in Community engagement and its impact on health and health equity.
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- Home - | - Episode 27: A Patient Story about Diabetic RetinopathyFor Podcast Episode 27, Dr. Rita Kalyani welcomes a person with diabetes, Derrell, who will be sharing his journey, living with diabetes particularly focused on the effect of diabetes related eye disease on his life. Along with Derrell, we are thrilled to welcome Dr. Sharon Solomon, an expert on diabetic eye disease, and one of Derrell’s care providers. Dr. Solomon is the Katherine M. Graham, Professor of Ophthalmology at the Wilmer Eye Institute, a retina specialist and board certified ophthalmologist. Her clinical expertise includes medical and surgical treatment of age, related macular degeneration, diabetic retinopathy epiretinal membranes, macular holes and retinal tears and detachment. She has a large national and international referral practice at Wilmer Eye Institute. Dr. Solomon is the first Wilmer faculty inducted into the prestigious Miller Coulson Academy of Clinical Excellence at Johns Hopkins.← Previous PodcastNext Podcast →
The post Episode 26: Diabetes and Hearing appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 25: Diabetic Neuropathy appeared first on The Johns Hopkins Patient Guide to Diabetes.
- Home - | - Episode 23: Diabetes & the Prevention of Kidney DiseaseIn Episode 23, we welcome Dr. Daphne Knicely, an associate professor of medicine at the University of Virginia school of medicine and an expert in diabetic kidney disease. Dr. Knicely is also the Physician Leader for home therapies at UVA Dialysis. She specializes in caring for patients with a wide range of kidney conditions — including acute kidney injury, chronic kidney disease, electrolyte disorders and kidney stones. Her clinical focus is acute and chronic dialysis in all forms (but with a particular interest in home hemodialysis and peritoneal dialysis), diabetic kidney disease and solitary kidneys.In this podcast, we talk about prevention risk factors in staging of chronic kidney disease for diabetes.
← Previous PodcastThe post Episode 23: Diabetes & the Prevention of Kidney Disease appeared first on The Johns Hopkins Patient Guide to Diabetes.
- Home - | - Episode 22: A Real Diabetes Parent’s StoryIn Episode 23, we welcome Dr. Daphne Knicely, an associate professor of medicine at the University of Virginia school of medicine and an expert in diabetic kidney disease. Dr. Knicely is also the Physician Leader for home therapies at UVA Dialysis. She specializes in caring for patients with a wide range of kidney conditions — including acute kidney injury, chronic kidney disease, electrolyte disorders and kidney stones. Her clinical focus is acute and chronic dialysis in all forms (but with a particular interest in home hemodialysis and peritoneal dialysis), diabetic kidney disease and solitary kidneys.In this podcast, we talk about prevention risk factors in staging of chronic kidney disease for diabetes.
← Previous PodcastThe post Episode 22: A Real Diabetes Parent’s Story appeared first on The Johns Hopkins Patient Guide to Diabetes.
- Home - | - Episode 22: A Real Diabetes Parent’s StoryIn Episode 22, we welcome Kim Vaughn, a certified registered nurse practitioner in the Division of Endocrinology, Diabetes and Metabolism at Johns Hopkins. Kim’s daughter was diagnosed at an early age with type one diabetes and Kim had to learn firsthand some of the challenges and rewards of parenting a child, with diabetes today she’ll be sharing her experiences, being a caregiver for a child with Type 2 Diabetes. In this episode, she shares her experiences of what it’s been like to parent child with diabetes.
← Previous PodcastThe post Episode 22: A Real Diabetes Parent’s Story appeared first on The Johns Hopkins Patient Guide to Diabetes.
- Home - | - Episode 21: Heart FailureIn Episode 21, we are thrilled to welcome Dr. Edward Kasper, that E. Cowles Andrus Distinguished Professor in Cardiology and Professor of Medicine at the Johns Hopkins University School of Medicine. He is the Director of Outpatient Cardiology and a specialist in heart failure. He is a fellow of the American Heart Association as well as a fellow of the American College of Cardiology. Dr. Kasper’s current research interests focus on the biological origins of heart failure. Specifically, his research has focused on causes and prognosis of patients with cardiomyopathy, a serious condition in which the heart has difficulty pumping blood throughout the body.
← Previous PodcastThe post Episode 21: Heart Failure appeared first on The Johns Hopkins Patient Guide to Diabetes.
- Home - | - Episode 20: Cardiovascular DiseaseIn Episode 20, we welcome Dr. Roger Blumenthal, the Kenneth Jay Pollin Professor of Cardiology and the principal developer of and Director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. He was Co-Chair of the 2019 ACC/AHA Prevention of Cardiovascular Disease Guideline. He also recognized as an expert cardiovascular risks related to diabetes.
← Previous PodcastNext Podcast →The post Episode 20: Cardiovascular Disease appeared first on The Johns Hopkins Patient Guide to Diabetes.
- Home - | - Episode 19: A Real Patient Story – Living with Peripheral Artery Disease (PAD)In Episode 19, we welcome a patient with diabetes, Antonio who will be sharing his journey living with Type 2 Diabetes, particularly focused on the effect of diabetes related peripheral artery disease and its effect on his life. Along with Antonio, we are pleased to welcome Dr. Elizabeth Ratchford, an expert on peripheral artery disease and one of Antonio’s care providers. Dr. Ratchford is an Associate Professor of Medicine and the Director of the Johns Hopkins Center for Vascular Medicine. Her research and clinical interests include peripheral artery disease, cardiovascular disease prevention, and fibromuscular dysplasia.← Previous PodcastNext Podcast →The post Episode 19: A Real Patient Story – Living with Peripheral Artery Disease (PAD) appeared first on The Johns Hopkins Patient Guide to Diabetes.
- Home - | - Episode 18: Healthy Eating TipsIn Episode 18, we welcome Asha Gullapalli, MS RD LDN CDE. Asha is a Registered Dietitian with over 30 years’ experience in the field of nutrition and dietetics. She has a Master’s degree in Clinical Nutrition, and is also a Certified Diabetes Educator and Insulin Pump Trainer. She provides counseling to people with diabetes, as well as developing diabetes prevention plans. She works with adults in the management of their diabetes, using motivational techniques and the latest technology to help them achieve optimal blood glucose control. In addition, Asha provides diabetes training to health care teams including doctors, nurses, pharmacists and dietitians. She likes to help change patients’ lives by encouraging them to make positive lifestyle changes and focus on “real” food ingredients having a more holistic approach to life.← Previous PodcastThe post Episode 18: Healthy Eating Tips appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 17: SPECIAL EDITION: World Diabetes Day appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 16: Nutrition in Type 1 Diabetes appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 14: Real Patient Story with Joanna appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 14: Real Patient Story with Joanna appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 13: Medications Taking Behavior appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 12: Medications for Type 2 Diabetes appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 11: Using Diabetes Technology appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 10: Staying Active with Diabetes appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 9: Coping with Diabetes Part 2: Goal Setting appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 8: Coping with Diabetes Part 1: Psychosocial Considerations appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post EPISODE 7: A Real Patient Story with Alan appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post EPISODE 6: Foot Care in Diabetes | Part 2: Seeing a Podiatrist appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post EPISODE 5: Foot Care in Diabetes | Part 1: Preventative Foot Care appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 4: Diabetes Self-Management appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 3: A Real Patient Story with Leon appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 2: The ABCs of Diabetes with Dr. Sudipa Sarkar appeared first on The Johns Hopkins Patient Guide to Diabetes.
The post Episode 1: Inaugural Podcast with Amy Rohrbaugh appeared first on The Johns Hopkins Patient Guide to Diabetes.