The Latest on Diabetes AM 570 KVI July 24, 2005 Dace Trence, M.D. Introduction

Transcription

1 The Latest on Diabetes AM 570 KVI July 24, 2005 Dace Trence, M.D. Please remember the opinions expressed on Patient Power are not necessarily the views of KVI, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. Introduction We're live on KVI. Got a question on how to be a smarter patient? Got a question on how to be a smarter diabetes patient? Call in now as Patient Power is live and ready to take your questions next on KVI. Good morning, Western Washington or wherever you may be on the internet. Great beautiful weather here, and in the forecast no rain they say on KOMO and KVI, so I am delighted. My daughter Ruth was on the show a few weeks ago. She's out on a rock climbing and backpacking trip. Hello, Ruth, have a great time out there. Wherever you may be today, if you're out there enjoying the weather and exercising and you happen to live with the condition we're going to discuss today, diabetes, exercise is a good thing. So we want to applaud you. But hopefully you'll listen for just an hour today as we talk about a condition that affects, oh, 15 million Americas or so. Many people don't even know it. There may be more who don't know it, and unfortunately it's an epidemic, type 2 diabetes that so many people have as they put on weight. It's a complication of weight gain. We would like you to call if you have a question or comment about how to be a smarter patient, whether it's diabetes or not, but we will focus some on diabetes today. We have one of the top experts in our region here in the studio, Dr. Dace Trence. She's the director of the University of Washington Medical Center diabetes care center. Dr. Trence, thank you for coming in early in morning. Really appreciate it. Good morning. My pleasure. And we were just chatting about so many issues related to diabetes. You know, Luther Vandross is a famous singer who died of complications of diabetes. There's no shortage of people, sports figures, Olympians, Halle Berry, type 1 diabetes. Della Reese, singer, type 2, probably. 1

2 Type 2. Right. Where she developed it as an adult. So we'll talk about that and help you do better with diabetes because if you don't do your part or a family member doesn't try to help you then there are complications, and it could lead to a shorter life and things that really affect your quality of life. But we invite your calls, and I always invite your calls about things that will empower other people. You know, last week if you were listening when we did the live remote from Cincinnati, Colleen called from Bothell just to share her story, how she's doing well. Received an from Rachel, who lives on the East Side, about how she was doing great, that a doctor saved her life. Send me those stories and call in. Now, I am so delighted to be on KVI. We've been on since February. You know, you can get smart about your retirement, the folks, the Ludemans before us, and you can learn about legal issues with the Brislawn folks after us. This is the place and really one of the only shows in the country where you can get smart about your health if you're living with a chronic disease or cancer and know better how to work with your doctor or find a doctor who is an expert. Last week it was thrilling to be with 300 people in Cincinnati where they'd come together on the internet primarily, and they have a fairly rare gastrointestinal situation, where the eosinophils, an uncommon kind of blood cell, inflames things. And so it so happens that the doctors in Cincinnati specialize in that. So it was a wonderful community, Dr. Trence, of seeing researchers and patients come together. How do we get better? How do we advance the research? Now, the University of Washington is very involved in research in diabetes, and I know you're part of that. And I want to thank the University of Washington Medical Center and Harborview for being founding sponsors of Patient Power, so thanks for that. And I think we'll have some additional sponsors to announce soon, a drugstore chain, and another major medical center. So we'll talk about that. Symptoms and Diabetes Management But let's go on to diabetes. Dr. Trence, it is an epidemic, isn't it? Oh, it certainly is, and it's getting worse. I think our statistics every year increase. You mentioned 15 million. Actually the most recent are 18 million people in the US affected with diabetes. And again, the problem is most of the those people, many of them, 50 percent don't know they have it. 2

3 Don't know they have it, so what would be symptoms? For a listener what would be signals that maybe something is going on. I think everyone knows the classic symptoms: The thirst, the going to the bathroom, losing weight without trying. But sometimes even fatigue. Very simple symptom, very common symptom, certainly not unique to diabetes, but it can be an alert that diabetes is present and should be checked for, particularly if there is a family history. Now, you mentioned about fatigue. So if somebody just feels like they don't have the get up and go they may not mention it to their doctor, they come in for other things. It sounds like you need that full communication where often checking it out further could lead to important management of a condition like diabetes. Certainly. Also giving a family history, as I mentioned, looking at what has happened in that person's own personal medical history. For women we look at what happened when they were pregnant. If they had gestational diabetes, clearly that's another risk for developing diabetes later in life. Why is diabetes scary if it's not managed well? I think everyone has in their minds a friend or a family member or a colleague that has had the complications, and immediately that picture flashes into the mind. For many people it's frightening to hear that word, diabetes. On the other hand I think we have now the knowledge to say that we can control, and certainly controlling diabetes means you have far fewer complications. It's not inevitable that you lose vision, it's not inevitable that you lose a limb. All these things are really preventable. So there's B. B. King on the TV ads and a younger fellow with diabetes. I can't tell how active B. B. King is. He's certainly still a great musician. His fingers are active. But you can live a long life. Yes. Yes. Absolutely. 3

4 But it takes the kind of thing they show, monitoring, exercise that I mentioned earlier, the proper diet and some medication in many cases. Certainly living a healthy lifestyle that we all know we should be doing makes good sense, but for the person with diabetes it makes even more good sense. Walking, exercising, I tell many of my patients exercise does not mean you have to swim to China and back every night. It means just going out for a walk, 20, 30, minute walk every day. We'll talk more about that with Dr. Dace Trence, who is director of the diabetes care center at the University of Washington Medical Center. And so much more. be right back with much more of Andrew Schorr's Patient Power. Thanks for joining us live this morning on KVI Talk Radio 570 for Andrew Schorr's Patient Power. I am Andrew Schorr today in the studio with Dr. Dace Trence, who is director of the diabetes care center at the University of Washington Medical Center. And thanks to UW and Harborview for being our founding sponsors on Patient Power. I want to mention a couple of things. First of all, if you haven't heard the news, great example of Patient Power, Lance Armstrong, testicular cancer survivor, seventh Tour de France. Great, great thing, and it shows that you may have a serious diagnosis, there is life after that. You may be living with a chronic condition, there is still plenty of life. But you've got to work just like Lance has done. Now, you don't have to be a champion bike rider to live well with diabetes, Dr. Trence. You said people can just go for a walk, but it does take some work and commitment to live a long, healthy life. That's just the way it is, but it is very doable, isn't it? Yeah, I think the challenge is the daily part of that. I think we all sometimes think, well, it's all great to go for a walk once a week, but the exercise component has to be daily. The watching the food intake has to be daily. The medications are daily. The checking the blood sugar is daily. There is really no shortcut here. Type 1 vs. Type 2: Okay. Now, we invite your calls. This is a chance to ask a top expert here who has been doing diabetes care for many years your questions about diabetes. And you can always 4

5 ask me about some tips on how to be a smarter patient. I'm working on a book with my friend Amy Gray called Patient Power, and we're coming up with sort of ten tips to Patient Power. I'll be happy to share that. Couple other things as we go on and talk with Dr. Trence, and that is there are wonderful resources for you, the America Diabetes Association and diabetes.org. Take a look at their website, a wealth of information. Over the years the company I founded, HealthTalk, did about 24 programs on diabetes, learned about monitoring, exercise, diet, and then the proper use of medications, which we'll discuss here, Dr. Trence. So certainly there is a lot of information. You are not alone. If you find out Monday that you're diagnosed with diabetes, if you find out that you've gotten overweight and a complication of your weight gain, unfortunately, was type 2 or adult onset diabetes, and now you will have it for the rest of your life, you can control it, but that's something you're going to have to deal with. Now, Dr. Trence, help us understand. There's children who are diagnosed with diabetes, and I understand that's type 1. Yes. And then there's type 2. What's the difference? Well, age really isn't the differential. Okay. You can develop type 1 diabetes - in fact the oldest person I've seen with brand new type 1 diabetes is 92 years of age. Wow. And you the youngest with type 2 has been six. So age isn't the determinant anymore. The difference between the two types of diabetes, type 1 is autoimmune. The body forms antibodies against the pancreatic tissue that produces insulin. With type two, it's a twofold problem. The first problem is that the insulin that's produced doesn't work like it should. It's there. We measure it. In fact oftentimes there's more than it should be, but it just doesn't work like it's there. As the body tries to compensate 5

6 for this the pancreas produces more insulin, and for a while that works. Unfortunately the pancreas after a while can't keep up, and so then the second part kicks in, and even for a type 2 person they produce less insulin. Now, where does obesity fall in to type 2 and the epidemic we have going on now with type 2 diabetes? When you are overweight then clearly the insulin doesn't work as well. There is insulin resistance. Interestingly, we're seeing insulin resistance also in that type 1. So you would think, well, if there isn't production of insulin how can there be insulin resistance. Oftentimes people with type 1 gain weight, and they require an increasing amount of insulin similar to that type 2 person. So we're seeing a lot of overlap. And I think there's been some interest now in that double diabetes, that was in the news just recently referring to that fact that sometimes the lines are a little blurred. Diabetes Diagnosis Now, you have treatment. So help us understand if somebody walked in next week and they were told, Mr. Jones, you are going to be a diabetic now. You have been diagnosed, let's say, with type 2 diabetes. It's come on later in life now, and this is the type you have. What steps do you go through? Some people, I've talked to people who say, oh, I'm controlling it with diet and exercise, and I guess some people are. Some people say, well, they gave me five medicines to take or I have to give myself a shot or maybe I'm going to get a pump. So there is a range there. There is a range, and I think the first step is clearly to look at what that blood sugar is. Then we make a determination what's needed for treatment based on the elevation of blood sugar. Oftentimes, as you mentioned, indeed just diet and physical activity can be means of controlling diabetes. It's still diabetes. I have a number of people who would say, well, I really don't think I have diabetes because I'm not taking medication. Well, that's not the case. But oftentimes dietary choices, exercise, they're just not enough. And it may also be a reflection of the progression of the diabetes. As time goes on, as I mentioned, that pancreas just doesn't keep up as it should, and then we start talking about usually pills. Occasionally, however, the blood sugar can be so high when the diabetes is diagnosed that insulin is needed as the first step. So there's a variety of approaches, again depending on what that person's needs are, and that's where monitoring that blood sugar is critical. 6

7 And as far as insulin goes, should someone need insulin you now have even different types, short acting and long acting, right? And intermediate acting and very, very short acting. So there's a variety of insulins. Is that when it gets complicated like that, a range of medicines and really taking an assessment of where someone is, that they would go see a specialist such as you and your peers at the University of Washington? That's an ideal time because then we can take a look at the program, look at what is needed to really give that person the flexibility to live life. Now, typically someone may be diagnosed and treated by their primary care doctor. So it could be--well, a child, I don't know whether a pediatrician would do it. With an adult, an internist, or I don't know if a woman's gynecologist would play a role. Help us understand where they get their regular care and what the care typically would be. There's a whole spectrum of how that diagnosis can come about. Oftentimes it's the physical examination that's done, and the person mentions the symptoms that we spoke about, the fatigue, the thirst, the weight loss. Sometimes unfortunately we make the diagnosis when the person comes in to the hospital through the emergency room with a heart attack. And sometimes it's the ophthalmologist, the eye specialist who looks in the eyes because someone thinks, well, I'm getting a little older, I can't see as well, and the ophthalmologist says, well, how long have you had diabetes? And the person says, what diabetes? So there's a whole spectrum of ways in which that can be diagnosed. Usually however the next step is to then get going on the lifestyle management that's needed for the control of diabetes. Establishing the diagnosis and then going ahead with monitoring. Now, this monitoring, like we see in the ads with B. B. King, whether it's that brand or many others, that's really the foundation of diabetes care, isn't it? Absolutely. How it your blood sugar doing today? How is it doing this hour? 7

8 Absolutely. That really is a critical tool. Unfortunately, it is expensive, but it gives that information that you just really can't get any other way. And it gives it right now. It's not what happened yesterday. When we used to have urine tests they would tell us three or four hours ago, that really is updated information. And to make judgments based on whether indeed you would give an extra dose of insulin that you're using, whether you might want to go ahead and take that walk or whether you might just say, well, maybe that wasn't the best of choices for lunch today, those are all pieces of information that that blood sugar really gives you. Now, give me some encouragement. If I were diabetic and I did my work, monitoring, if there were medications involved, doing that, the proper diet, can I live a long, normal life? Absolutely. You certainly can control what happens to you by putting a lot of energy and effort into this. Okay. So we mentioned about maybe 18 million people with diabetes and many undiagnosed and don't even know it. So there's someone driving their car, they're going off for a great activity today and they say, well, you know, I don't have diabetes. I don't think I know anybody with diabetes. Probably not true, right? And it is something to pay attention to, to have surveillance for. Absolutely. I think certainly with many of the blood tests that are now done routinely, the panels, the blood glucose, that sugar level is checked. Heart Disease and other Diabetes Complications: Okay. You mentioned about people coming into the emergency room with a heart attack, and then they find out they have diabetes. What is the connection between the heart and diabetes? I think most people are very aware that diabetes and eye problems, diabetes and kidney problems, diabetes and infections go together, but a lot less awareness of the large vessel disease in the body, the vessels of the heart, the vessels that go to the brain, the vessels that go to the legs. We call that large vessel disease, and that really is at the forefront for the complications that we worry about, particularly with type 2. 8

9 So what happens then? Would somebody who typically is diagnosed with diabetes take some medicine to try to prevent those stroke, heart attack issues? We actually now think of diabetes as more of a metabolic syndrome, a stew, if you want to call it that, a soup. It isn't just blood sugar. Blood sugar can be a great marker, and we certainly pay attention to that, but blood pleasure, blood cholesterol, all these things go together. And we don't know which of these is the most important. We have research right now trying to identify whether it may be one of those that we should really be putting all our energy into, but until then it's a little bit of a shotgun approach because we just don't know which of them are the most important. When we continue after the break I'd like to talk about what heart medicines or blood pressure medicines you would recommend typically for somebody with diabetes, classes of medicines anyway, and see where that comes in and try to head off these complications of diabetes. We're visiting with Dr. Dace Trence, who is the director of the diabetes care center at the University of Washington Medical Center. We'll be right back with much more. Welcome back to Andrew Schorr's Patient Power. I'm Andrew Schorr live in the studio ready for your calls today about Patient Power but about diabetes. We have a top expert here. Dr. Dace Trence, the director of the UW Medical Center diabetes care center and I were chatting during the break about how so many people think they've got their diabetes under control, and unfortunately, Dr. Trence, maybe few you really do, right? Many people work hard at it. Many people could work harder at it because it's really critical to their long-term health. We actually have a wonderful tool called the A1c, which is a blood test that reflects the previous three months of blood sugar control. It's a number everybody should be very well acquainted with if they have diabetes, and we're seeing that number as a target become lower and lower and lower as the recognition that blood sugar control can help manage the complications becomes much more established. And I've heard it said, I've attended some diabetes conferences so now the medical professionals are saying know your numbers. So one is your A1c. But there are a couple of other numbers. Your cholesterol and your blood pressure, right? Right. 9

10 What should those be for someone who's living with diabetes? I have had heard it said that it should be, your number should be your blood pressure as if you'd already had a stroke or your cholesterol as if you were already somebody who had had a heart attack even if you hadn't. Particularly for those type 2 folks, exactly. The risk is so high for that heart problem that we talked about. In fact if you look at the studies we have certainly people are encouraged to target that LDL cholesterol, which is that heart bad cholesterol, that heart risk cholesterol to now a level at least less than 100 and more typically actually less than 80, and if you've had a heart attack, less than 70. So we're pushing lower and lower and lower, but the data are there to support that that's the way to approach it. And blood pressure? Blood pressure, 130 over 80 is now the upper limit, and a lot of people are feeling that maybe closer to be 120 over perhaps 70 or 75, again if there has been already evidence of heart involvement or if there has been evidence of a kidney problem. These are tight numbers. Very tight numbers, and of course they're not reachable without medication. Let's talk about that. So if someone comes to see you, they're a diabetic, type 2 diabetic, let's say, and they don't have those numbers, what are you going to do? Well, we sit down and we have a talk about additional medication. It isn't just the diabetes controlling medication, but then it's the blood pressure medicine. And we look at a lot of different categories. One of which we use quite a bit of in diabetes are called the ACE inhibitors, Angiotensin-Converting Enzyme. Kind of an alphabet soup there, but they are excellent drugs that help control blood pressure, additionally help minimize kidney damage, can also help the heart work better. So they tend to have a wide variety of effects. Now, you may need a cholesterol-lowering medicine as well. 10

11 Oh, that's true. Sometimes when I see people we talk about this and they say, well, how many more do I have to take? And that is a problem. People sometimes leave with a basket full of medications, and of course they always are concerned, rightly so, about potential side effects. We always weigh the benefits with the side effects, and clearly I think here the benefits far outweigh the side effect potential. And you mention about kidney problems. Now, if diabetes is not controlled there is damage that may well happen to your kidney, and then you will be one of those people who have kidney failure, maybe on dialysis, and I know there are people listening who are, and it's a difficult road, who are waiting for a transplant, and all too few transplant kidneys available. So you don't want to go there if you can help it. That's why we spend so much time initially to try and really address the attention to blood pressure and address the attention to better blood sugar control, all the things that we know can have an impact. Now, don't be shy. If you're out there and you're living with diabetes or you have a grandpa who is or your mom or dad or yourself. Dr. Trence, as we continue related to diabetes then you mentioned a basket full of medicines. That's hard. And you say people worry about side effects, and these medicines do have, there's no free lunch. Powerful medicines, they affect different people differently. So if there is somebody out there who is supposed to take a medicine, they just never do it, I don't feel right. That's really where they need to go back to their doctor, nurse practitioner, whoever it may be, and speak up, right? Because you can make changes. Yes. We are not limited to just one class. Although there may be one class, as I mentioned, that works better than another, we certainly can try others. The problem with diabetes and particularly blood pressure is a good example is that oftentimes it may take two or three medications to control that blood pressure. And that I think also sometimes is very frustrating for the person trying to do the best they can. How do I take this? Can I take this once a day? Do I have to take this twice a day? Keeping track of it all, and it's really a challenge. But people are different, and so you're trying to individualize dosage and the right medicine for them. 11

12 Yes. And we work a lot at how can you actually accommodate that medication. We have people who work different shifts, and we have people who say, well, I take medication better in the morning because I can remember it. So we work with, well, what do you do in the morning? Do you brush your teeth in the morning? Well, then take that bottle of medication and attach it to the toothpaste. There are things that one can do, but you have to discuss the challenges and the issues. Listener Questions: Dr. Trence, we woke them up. They're calling. Thank you for calling. That's why we're here live. Let's take a call from Mike. He's on his cell phone. Mike, where are you now? Hey, I'm in south Redmond right now. Okay. And what's your question or comment? Well, my question or comment is I don't hear the doctor and yourself talking about insulin resistance. I heard it just briefly mentioned and measuring your insulin level and syndrome X and the affects on heart problems, triglyceride, cholesterol problems, obesity and diabetes, there's that theory of syndrome X that they're all interrelated. Okay. We're going to talk about that. Are you living with diabetes yourself, Mike? No. I was apprehended. What do you mean? I was becoming insulin resistant, and I went to some private doctors who actually measured my insulin level instead of muddling around looking at symptoms, and basically I reduced it from 69 in early December down to 9 in January, and I just keep on the insulin resistant diet, and my cholesterol has dropped close to 30 points as well. Well, good for you. Let's find out more from Dr. Trence. I'm going to let you listen off the air. Thank you for calling in today on Patient Power. I'm glad you're doing well. 12

13 Good. Thank you. Thank you, Mike. Okay. Well, what is syndrome X? What's he talking about? Help us understand that. Syndrome X is getting a lot of attention. It's a great question. It isn't something that is necessarily diabetes, although we do look at fasting blood sugars and by definition over 110, some people feel over 100 now should be part of that syndrome. But it is blood pressure greater than 130 over 80. It is having triglycerides that are over, those sugar fats that are over 150. It's having increased waist circumference. For men that's defined as greater than 40, and for women it's greater than 35 inches. So it is this complex of different kinds of features that we feel certainly has a high risk if anyone has it for the development of diabetes but also a very high risk for heart disease. Now, I've heard the term "prediabetes." Is that related to this at all? It fits into that category. It isn't the whole descriptive part of metabolic syndrome, but it certainly is part of it. It is that definition that we used to call impaired glucose tolerance but now have changed it to prediabetes because the risk of going on to diabetes is so high. It's 11 percent over three years, and that's a lot if you have prediabetes. Do you have tests for that? Yes, same thing that we do for diabetes. We check the blood sugar. Okay. We'll have to talk more about that if we have time, and the research, where the research is going. But Steve is with us in is it southwest Seattle, Steve? Is that where you're calling from? Yes, Burien, Highline area. Well, welcome to Patient Power. What's your question or comment? 13

14 Basic question is the low blood sugar, people who have that. I go to diabetes groups here for the past two or three years at two different places every month and with a support groups and very interesting and helps keep a lot of us in line on our own at least and going to see doctors, etc. But I'd like to hear more about the low blood glucose because in a couple of our support groups we've had people get low because if they hadn't got been caught by some relative or spouse or something they probably wouldn't be around to continue to go to support group. So I want to understand. This is the reverse of the high numbers we were talking about. Yes. I know there's so much about diabetes. I'm a type 2 diabetic, it's been known since 1996, and I came in control of my diabetes within a six-month period of watching diet and counting my carbs and all that kind of stuff and calories and what have you. So I got down there, but I'm still taking medication for it, and I'm sort of losing control in that because I don't really walk a lot. I don't walk hardly much at all, but I do keep reasonably active. My weight is down. I got it down pretty fast, within a half a year, and it's been holding very steadily. Good for you. My lipids and everything else, blood pressure have been in the ball park. The big thing is my A1c, 7.7, about, last month. Okay. We're going to get some comments on that and then more after the break. I'm going to let you listen off the air. Steve, thank you for calling in and best to you with your support groups down there. Yeah, thanks for the program here. Thank you, sir. Well, let's begin our answer before the break and that is about low blood glucose reading. And that is a risk, and certainly it's an increased risk as blood sugars get into a more normal range simply because the medication that we have does potentially bring that blood sugar down even further. Sometimes when it's a frequent occurrence, such as with 14

15 the caller, it may be worth again looking at the medication, looking at the type of medication, looking at the timing of the medication just to see if that's preventable. The problem with low blood sugars is when they're increasingly present is that the body begins not to see them and so the signals become blunted, and people indeed don't recognize that their blood sugar is at 60 anymore, and they take a 50 or a 40 before the same signals come in. So it's a moving target, and that's the regular monitoring and communication with your doc. Very much so. We'll talk more about the importance of communication with your provider and the monitoring as we continue today talking about diabetes on Andrew Schorr's Patient Power live on KVI. We'll be right back. Welcome back to Andrew Schorr's Patient Power live in the studio. Talking about diabetes today. Thanks to Mike and Steve for calling in and sharing their story. It's about 17 minutes before the hour on a beautiful Sunday in Northwestern Washington. I was noticing back East there's a heat wave, really hot, but here we're blessed with the most gorgeous weather in the country. And so if you're living with diabetes, great day to put one foot in front of the other and do some exercise. Couple of quick announcements. First of all, speaking of exercise, next week is the Swedish Medical Center Run For Ovarian Cancer. Patient Power will be there live to do a live remote and learn more about the latest in ovarian cancer, meet some women who are living with it and the latest in care for that very serious illness. So that's why we'll be, just up on First Hill live. Do the run. If you're diabetic, take a walk and do everything you can. Also, during this last week the pharmaceutical industry came out with direct to consumer guidelines for their ads, and many of us get a little tired of all the ads and say what else can you do. And I think now they'll be more committed to education. Hopefully they'll support a program like this. Dr. Trence, lots of medicines we mentioned that people take for diabetes. Steve who called in from the Burien area is taking a lot, I'm sure. You winced a little when he said what his blood sugar number was,

16 And Steve is already doing a lot. Well, that is a challenge, that 7.7. The guidelines we have now suggest that 7.0 from the American Diabetes Association is really the target. That translates to an average of 150 for a blood sugar in the preceding three months. There are other organizations that really feel it should be tighter, 6.5. The American Association of Clinical Endocrinologists, the Canadian Diabetes Association. I think sometimes we fixate on these numbers. They're good as guidelines, they're good as indicators of averages, but if that average is 150 and you're spending time either being 40, which is very low, or 240, which is quite high, that average doesn't really have much meaning. So you have to really look at day-to-day what's happening rather than just assuming that that average gives you the whole picture. And that's your communication with a provider. And Steve is in a support group, and that's great. Wonderful. So there are people out there to help you. I mentioned the American Diabetes Association earlier. Give them a call. There is a wonderful chapter here, and there is in almost all cities and states. Just go to diabetes.org or go to the phone book, American Diabetes Association. You can connect with a support group. You can connect with diabetes specialists if you don't have one, and you can also--sometimes you're going to need counseling because this is tough to have a chronic condition, and every day you get up with it, and there it is again and there is a group of medicines. There it is again. Steve has a number that's a little bit high and he says, oh, what am I doing wrong. It's got to be very frustrating. You don't have to be alone, right, Dr. Trence? That's the problem. It isn't like there's something wrong. It is that frustration of why doesn't this go away. I do everything I'm supposed to, it's not like an infection where if I take my antibiotics or do something in seven days or five days or three days, I'm fine. This is every single morning facing the same decision process. Very, very challenging. Now, for those of you who are not touched by diabetes, who otherwise would be because the rate is high, manage your weight. That is definitely something that could make a big difference in whether you develop type 2 diabetes, correct? 16

17 I certainly think that for our first speaker that's probably a lot of what helped him deal with his insulin resistance. That is part of what triggers that insulin resistance, although it isn't the whole picture. I think our research is trying to find out what actually is the whole picture, because then everybody who is overweight would have diabetes, and everyone who is overweight would have insulin resistance, and that's just not that simple. So family history certainly plays a role. Very much so. Ethnicity plays a role. Some ethnic populations have a much greater risk. Which are those? Hispanic population. The Asian population we're learning also is at great risk. The American Indian population certainly. So a lot of ethnicities, yet it seems to be related there to that weight adding to the ethnicity. Latest Research Okay. Now, as far as your research, you had your big American Diabetes Association conference in June in San Diego, I believe. Yes, very exciting. What was exciting about it? Well, one of the things that we learned with type 1 diabetes is that if you have a period of time where you maintain good control, as tight control as possible, as near normal blood sugar as possible--and for many individuals that meant an A1c that was just a little bit above 7, which is not perfect, but that buys you actually fewer complications, many years later even if the control is not as good, which is astonishing. We knew during the times of study that certainly affected development of eye problems and kidney problems, protected one against that, but now taking that same information years down the line it's like there was an imprinting in the body of some kind with that better sugar control. So very exciting to hear that. 17

18 And you're doing a lot of research at the University of Washington, so there is the chance of people getting tomorrow's medicine today or at least being part of that investigation. Is there a number to call or website to go to if they want to find more about diabetes research at the UW? We do have a website at the U, and also our number, , area We have a number of studies that are ongoing right now. We are looking at different delivery systems with regards to insulin, different medications. It's an exciting time actually in diabetes. Well, terrific. That's very hopeful. Listener Questions Let's take a quick call from Don. Don is calling in. Where are you calling from, Don? Well, I'm on the road between North Bend and Renton right now. Okay. And you have a question about fasting sugars, is it? Yes, I do. I had them pretty well in control and then my mornings started going up. I'd been down to a half a tablet of the--dosage is 500 milligrams of metformin. Metformin. Metformin. And now I'm back up to a half a tablet mornings and evenings. But in the afternoons I find that I crashing quite often, even beforehand. And I was wondering, you know, meals are usually an hour or an hour and a half away before you can get to one. Is there anything you can do to just temporarily bring your blood sugars up enough that you don't have to worry about eating again? 18

19 Right. Good point. Don, I'm going to let you listen on the air. Drive carefully there. We'll get you off the cell phone, and we'll talk about it. Okay. Thank you so much for calling in. Thank you. That's a very good question. Clearly there are things that one could have in the car that are easily accessible and don't get bad with time. Glucose tablets are available. There are tablets that come in huge jars usually for something, huge Costco type of jar you can get for nine dollars or so, or even small amounts. And they're tablets that are designed to be taken three to four at a time. I think many people think if I take one that's going to be it, but about four will give you 15 grams of carb, which is what it takes to treat a low blood sugar. You chew them, not all at the same time because they're rather big, but you chew one at a time to get the absorption in, and then in 15 minutes recheck. Other things that can be carried certainly is small cans of juice. Again, look for 15 grams of carb. You don't need the entire can of juice, which oftentimes can be 30 to 35. A little box of raisins can be carried. So those are all excellent tools to have. Now, when diabetes is more advanced, let's say, or more insulin dependent, then there are short-acting injections of insulin that somebody might take as well. Those should be reserved, however, for when the person can't take anything in by mouth. Okay. So the oral and the simple things you were describing are readily available and that could help Mike on his drive today. Certainly could. There's a little tube that has a very concentrated form of syrupy, very sweet, not one that one would tend to take unless you really needed something. Also can be put easily in the glove compartment, and you just snap off the top and squirt it into the mouth. 19

20 So, Dr. Trence, you've been at this a while, number of years, and you've learned these ways of working with thousands of patients. So it sounds to me like an active dialogue with your provider, if you need to see a specialist at the UW such as yourself and discuss these issues as you're going through life and recognize that diabetes is kind of a moving target, if you will, where Mike would take a pill and that dose worked fine and now he's seeing a change. So it's an active dialogue. It isn't the same disease from one year to the next for people. I think that sometimes tends to be forgotten. So what does work one year may not work the next year. The change in medication, the type of medication, the doses, addition of a new one, all these things need to be discussed with the healthcare provider. Well, that's an important point, and there are people there to help, people such as you, your own primary care doctor, and the American Diabetes Association I think is a great resource. We'll be back with more on this wonderful, important topic and other Patient Power topics as we continue right after this. Stay with us. We've been visiting today on Andrew Schorr's Patient Power live with Dr. Dace Trence, who is the director of the diabetes care center at the University of Washington Medical Center. She works with my friend Dr. Earl Hirsch, who is a terrific guy and has been on the show before. Dr. Trence, what you want people to hear more than anything else related to diabetes care today. You are in control. Ask questions. This is where you really can make a difference. If you are not feeling well tell someone. Tell your provider, tell your nurse practitioner, your nutritionist, but really you are the main person responsible for your care. And with the array of medicines and monitoring and diet and exercise there is a lot you can do to help people live a long, full, happy life. Yes. 20

21 Okay. So it's the dialogue. It's work if you have diabetes. Certainly children who are diabetic, and many of them get these pumps implanted now to make it a little easier, but they go on and they're regular kids, and you can be that way. So I wish you well. Dr. Trence, thank you for being with us. Thank you. And thanks for all you do at the University of Washington Medical Center and the diabetes care center. I want to mention a couple of other Patient Power news. First of all, if you are of Medicare age or you are disabled and you are someone, they like to say people with Medicare now, I want you to write this date in your calendar, Saturday, October 15th, when our plan is to do a whole town meeting either in person or on the phone or on the internet to help people understand the prescription drug benefit that will be available that you can choose to be part of with the 43 million people who are on Medicare. So Saturday October 15th. We believe it's going to be a big town meeting happening where you are, Dr. Trence, at the University of Washington Medical Center. So hold that date. Many organizations like the American Diabetes Association are helping us put that together. The other couple of things is I do a program on Saturdays too that unfortunately is not heard around here. It's on a new health radio network, but if you go to healthradionetwork.com, go to Archives and Patient Power, you can hear what we've been doing. Yesterday was on depression, and that's a tough one too. So take a look at that. And then all of the replays of those programs and these programs will end up on a website I'm building, patientpower.info. So I'll announce that when that's out there. But I want to thank Dr. Trence for being with us. I want to thank the UW Medical Center and Harborview for being founding sponsors for Patient Power. There are others that are coming. If you can go up to First Hill in Seattle next Sunday, 8 a.m., there is a big ovarian cancer run, the Marsha Rivkin Run. And we'll be broadcasting live there, so come say hello if you're going to be there and learn more about cancer. Fortunately there is progress being made in cancer too. So for me as a leukemia survivor today where right now they can't find it, knock on wood, I hope it stays that way, benefitting from being in a clinical trial. And, Dr. Trence, you certainly have trials too. What was that number one last time? One more time. 21

22 For the latest in diabetes research at the UW. Thanks for being with us and be back next week when we will be up on First Hill in that ovarian cancer run. Tune in. Thanks for being with us today. Have a great week. This has been Andrew Schorr's Patient Power live on KVI. See you next week. Please remember the opinions expressed on Patient Power are not necessarily the views of KVI, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. 22