Managing diabetes after age 50

Podcast transcript

INTRO
Welcome to Docs in a Pod presented by WellMed. Over the next half hour, Docs in a Pod will educate you about the health and wellness of adults everywhere. Co-hosts Dr. Rajay Seudath and Carmenn Miles will share information to improve your health and well-being. And now here are Carmenn Miles and Dr. Rajay Seudath.

CARMENN MILES
Hello everyone and thank you so much for joining us today on the award winning Docs in a Pod presented by WellMed. I'm Carmenn Miles and I'm excited to jump into another great conversation centered around health and wellness topics that really matter, especially for our seniors. If you're listening in for the first time, you can find this podcast on any podcast listening platform. We're also available on the radio and several Texas markets. Each week we share practical health information that hopefully helps all of us live healthier, happier lives. So, we're thrilled that you're tuning in. We have a great topic for discussion, but before we go there, I want to introduce our resident co-host for today. Dr. Rajay Seudath is no stranger to this show. He's a proud Tampa native, a board certified family medicine doctor and the lead physician at the University location for Optum. He brings great passion to primary care. He's a wealth of knowledge that makes health issues very simple and plain and easy to understand. And that, my friends, is precisely why we love having Dr. Seudath as a resident co-host on the show. How are you, Dr. Seudath?

DR. RAJAY SEUDATH
Thank you so much. IÕm doing great. I'm happy to be back.

CARMENN MILES
We're happy to have you. Listen, we've got a great guest, a return guest doctor today. Dr. James Dinn knew at a young age of five that he wanted to be a physician. When Dr. Dinn's brother was diagnosed with a chronic illness, his family spent years looking for a physician who would simply listen. That's so important when you're dealing with a physician. Today, Dr. Dinn strives to be a physician who truly hears his patients. He's a Texas native. He completed the entirety of his medical education in my hometown of San Antonio, Texas. He attended the University of the Incarnate Word School of Osteopathic Medicine and graduated with honors before completing his internal medicine residency at the Texas Institute for Graduate Medical Education and Research. His care philosophy embraces intentional listening, which he believes greatly aids in making proper diagnoses. Welcome back to the show, Dr. Dinn.

DR. JAMES DINN
Thank you for having me back again. I'm excited to be here.

CARMENN MILES
Thank you so much. Well, everyone, we have a great topic for you today. We're talking about diabetes. What is it? What are the complications that it can cause? And most importantly, how we can prevent those complications and live healthier lives? Just a few stats. Over 800 million people are living with diabetes globally. That's roughly 1 in 9 adults worldwide. In the U.S. alone, about 40 million people, suffer with diabetes. That's roughly 1 in 8 Americans, or about 12% of the population. 115 million in the U.S. have prediabetes. You'll have to tell us the difference, basically meaning that they are at high risk of developing diabetes. Clearly the stats show diabetes is a major global health concern, and so many people go undiagnosed. They're not even included in those statistics. The undiagnosed individuals increases the risk of complications. So, if you aren't dealing with diabetes yourself, it's likely you know someone, a friend, a family member, or maybe even a colleague who has diabetes. The term diabetes itself is not foreign to most people, but as aware as most of us are of the disease, most do not have a grasp of what actually causes diabetes. Dr. Dinn, before we dig into the meat of things, can you just break down diabetes and what causes it in a way that we can all understand and grasp how diabetes presents itself within our bodies?

DR. JAMES DINN
Absolutely. You did a great job with the statistics. I'd like to share a couple of more. By 2050, that number is projected to be 1.3 billion worldwide. That's horrifying. It's a 60% increase from where we are now. In the United States, that's currently 1 in 9 Americans. A number that should stop you in your tracks is global diabetes related health spend hit 96,000,000,000 in 2021, nearly $1 trillion. And it's only going up. Tragically, about 6.7 million adults die from diabetes every year. That was the number, I think estimated in 2021. So, you've kind of hinted at the fact that not everyone knows they have diabetes. About 45% of the world's diabetics don't actually know they have it. To answer your question, there's two types roughly, that's what we'll stick with for today's podcast. Type 2 diabetes accounts for 96% of all diabetes cases globally. Here's the kicker. Prevalence exceeds 10% in people aged 30 to 34. It's not just a disease of the elderly as some people think. So, what is it? Simply put, it's insulin resistance. The way your body's built, the things you eat, your genetics all contribute to, I would say, something called insulin resistant. Over time, this can lead to insulin depletion and a failure to produce it all together.

CARMENN MILES
Dr. Dinn, not to cut you off, let's take a moment to welcome those who may have just joined us. You're listening to the award winning Docs in a Pod presented by WellMed. Our podcasts are available wherever you listen to your podcasts. We're also available on the radio in several Texas markets. I'm Carmenn Miles alongside Tampa native Dr. Rajay Seudath, our co-host today, and Dr. James Dinn, our guests from WellMed at Division in San Antonio, Texas. He's with us today to help us break down diabetes, the different types of diabetes, how to manage the complications it presents in order to live a healthier life. Carry on, Dr. Dinn.

DR. JAMES DINN
Absolutely. That was the breakdown of just diabetes in general. That's the nuts and bolts of kind of what you need to remember. So, what makes it dangerous? It's not just the high blood sugar. It's what the sugar does to your body over time. Think of it as like, rust slowly corroding pipes. Diabetes damages blood vessels big and small and leads to two categories of complications. The small vessel damage we call that microvascular complication. That is things like your eyes, your kidneys, nerves, feet. The five year mortality rate, this is just kind of a fun fact or terrifying fact rather. The five year mortality rate after a major amputation from or associated with diabetes exceeds 70%. That's worse than many cancers. Just to talk about feet here, approximately 18.6 million people worldwide develop a foot ulcer each year. These ulcers precede about 80% of all lower extremity amputations in people with diabetes. Once you've had one, the recurrence risk at five years is about 65%. So, that's the feet. The eyes are another one. Diabetes is the leading cause of blindness in working age adults. The lifetime prevalence of any retinopathy in type 1 diabetes is a staggering 95 to 97%. Thankfully, it's much rarer in the type 2 diabetics. And this is something that's relatively preventable, particularly when early detection and tight control are maintained throughout the duration of your life. The diabetic nephropathy, that's the kidney disease. 20 to 40% of people with diabetes will develop it. Then the diabetic neuropathy, that's 25 to 35% of people living with type 1. The numbers for type 2 are less specific, but it's the gateway to one of the most feared complications and that's the foot ulcers we've already addressed. So, for the docs who are listening, multi-disciplinary foot care teams, podiatry, vascular surgery, infectious disease, when you see these things, get in early. Your biggest friend in this battle is going to be the CGM. Your continuous blood glucose monitor. It doesn't matter if it's Libre, ever since, Dexcom. Pick one. Get them on it. Whatever one protects you long-term.

DR. RAJAY SEUDATH
Whatever one the insurance covers, that's the one we want.

DR. JAMES DINN
Exactly.

DR. RAJAY SEUDATH
One of the things you talked about, which was the ulcer kind of being the gateway to an amputation. The amputation being the thing that leads to that high risk of mortality within five years, dying within five years. Being worse, statistically, than some cancers. We often don't want patients to clip their toenails. We want them to see the podiatrist. Oftentimes, it's just a simple, do you look at the bottom of your feet after you come out of the shower? You'll be surprised how often patients are like, what? When you dry your body, do you twist your leg and look at the bottom of your feet? No, not on a habit. Have you noticed any stains on your socks? Do you notice any wet spots in your shoes? Those kinds of things. We've caught quite a few of those things before they developed into something serious, especially people who are living by themselves who don't have a partner, who don't have a son or a daughter or someone that they see who's noticing, oh, your feet are kind of nasty, dad. Sometimes us as the providers, I know in my clinic, diabetics always take off their shoes. The staff, the medical assistance, everybody knows Dr. Seudath wants to look at their feet. He's got a thing for feet when it comes to diabetes. I thought that was that was interesting that you brought up. I didn't know that five year statistic with the mortality being so high. I knew it was high. I just didn't know that specific number for 2021. Another thing was the eye exams. Making sure that we are sending our patients to get eye exams so that they can find that early detection. I think you hit the nail on the head that early detection, being able to intervene early. And sometimes that can also be a driving force to get people to lower their sugars. If they're like, I feel fine, doc, I don't care that it's 300. I feel good, I feel strong. Seeing the changes that are happening in their eyes and telling them, hey, you went to the eye doctor, they said you've got retinopathy. You could go blind. If we can do that before they get the floaters, before they get the piece of their vision getting removed and they're seeing these changes, if we can intervene and help them, sometimes that's one of the things that can make a big difference later on. So, I think you absolutely, covered that so well.

CARMENN MILES
I agree. Gentlemen, we need to take just a quick break, but please stay with us as we continue this great conversation on how to manage complications of diabetes. You're listening to Docs in a Pod presented by WellMed. We'll be right back.

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CARMENN MILES
We're back on Docs in a Pod. I'm your host, Carmenn Miles, with co-host Dr. Rajay Seudath and our guest today, Dr. James Dinn is breaking down diabetes for us today. Dr. Dinn, a few questions for you and Dr. Seudath going into the balance of today's chat. Why do you believe so many people go undiagnosed? And what's the importance of getting diagnosed early? You've touched on that a little bit. You've also mentioned a few of the complications that diabetes presents, but I want to go a little bit deeper. Because diabetes affects a lot of areas for us. Go right ahead, Dr. Dinn.

DR. JAMES DINN
Absolutely. So, we talked about the diabetic foot ulcers and amputations. We talked about diabetic retinopathy. We talked briefly about nephropathy, so I'd like to finish up with that. This, again, occurs 20 to 40% of people with diabetes and a major cause of end stage kidney disease requiring dialysis or transplant. This is part of the reason that you should see your doctor at least yearly. Ideally get it controlled, then you can consider six months, but it should be probably every three until you're under control. Diabetic neuropathy, 25 to 30% of people with diabetes will develop this or have symptoms of it. I'd like to talk about the microvascular complications. Diabetes is referred to as a coronary artery disease equivalent. Why? Because of the pathophysiology associated with vasculature. So, heart disease is the number one killer of people with diabetes. Cardiovascular disease once accounted for more than 50% of deaths in people with diabetes. Stroke and peripheral artery disease round out that microvascular trio. So, here's the thing most people don't realize. With better treatments, cardiovascular death rates and diabetes have actually been declining. But that's revealed a new set of problems. Cancer and dementia are now emerging as leading causes of death in people with diabetes in some countries. Diabetes is linked to cognitive decline, depression, sleep apnea and liver disease. Also, none of this is surprising to anybody who studies pathophysiology. What I want to talk about here is something that was called the UK Prospective Diabetes Study or UKPDS. Why I want to focus on it is because it can hopefully lead you away from all these complications, prevent them before they even happen again. It's using something called the legacy effect or metabolic memory. People with type two diabetes were studied for 40 years. That's one of the longest clinical trial follow ups in history with 80,000 person years of data. What they found was good blood sugar and early control, these people had fewer attacks, fewer complications, and lived longer, even 24 years after the trial ended. There was another study that was in type 1Õs and they basically found the same thing. What does all of this data mean? I get bogged down in some of the data, but I need you to know where it came from. Think of it this way. Your body remembers high blood sugar. Every year, poorly controlled diabetes leaves a permanent mark on your blood vessels. But the flip side is also true. Every year of good control, particularly early on, pays dividends for decades. So, for the docs, if you're listening, the mechanism likely involves advanced glycation end products, oxidative stress, and epigenetic changes that enhance pro-inflammatory gene expression. Critically, just something to remember, each percentage point higher the A1C seen 20 years before death confers 36% increased relative risk for death, compared with just 8% for values in five years before death. So basically, the longer you keep it low, even if it's not at seven, the better off they are long term. This is not the same with some of the other things you see with diabetes. Blood pressure, there's no legacy effect. Cholesterol, no legacy effect. This seems to be very specific to diabetes. Again, probably because of the pathophysiology.

DR. RAJAY SEUDATH
Absolutely. I think it's also because of the way that we measure A1CÕs. It's a three month measurement of the blood. It's not like a snapshot in time with the blood pressure or things like that. I think it makes sense. I like the way that earlier in our talk, you had said it's like rust. Think of it as rust on pipes, and it's exactly right. If we're using that same analogy, if you've got things going through the pipes that are going to cause corrosion, it's going to speed that effect up. Similarly, if you have super high sugars, if you're having sugars in the 300Õs or 400Õs and you're not doing anything about it, your body is going to be affected by those high amounts for longer periods of time. Just like you said, the opposite is true. Bringing down those sugars, getting them into the 120s, getting your A1C below seven or as close to seven as possible, those are going to pay dividends, like you said, because that oxidative stress, that rust on the inside of your pipes, what we're doing is we're effectively decreasing that corrosion. I think for our patients, that's a really good way of explaining that to them. I think that legacy effect, and I wasn't aware of that study, so when you said legacy effect, I was like, oh, I know exactly what you're talking about. But I didn't know those actual numbers. Now there's actual numbers, so if you have a skeptic patient that is like, I don't believe anything these people say. You guys are just trying to make a buck off my corpse. No, we can direct you to actual numbers. For the skeptic patient, that's actually a very good tool for us as clinicians to point forward. So, I think that's great. I like that idea of that legacy effect giving such longevity to patients and letting them know that. We can say this is going to this is going to help you out for 20 or 30 years, and it really doesn't have any weight to it. But now that we can show that yes, these are the numbers. 40 years of studying people show that they have less events that could be a life changing event, whether it's a heart attack, stroke or kidney disease, going on dialysis, that kind of stuff.

DR. JAMES DINN
Yes, sir. Or lack thereof in this studied population. So, control it early.

DR. RAJAY SEUDATH
Right. Exactly.

DR. JAMES DINN
I would like to talk about the pillars of protection. Blood sugar control is obvious. Again, CGM. That's again, continuous glucose monitoring.

CARMENN MILES
I was getting ready to ask what is CGM? I have not heard that before. Thank you.

DR. JAMES DINN
Again, whatever your insurance covers. Libre is $60 for cash pay patients, just as an FYI. Even if your insurance doesn't cover it, you can get it at Sam's or Costco with a coupon that you can get online. Blood glucose is one of the pillars. We'll talk about it briefly a little bit later, but I want to get to the other pillars. Blood pressure is the second pillar. Recent guidelines now suggest, and this was the BP road trial, that we target 120, even in adults over 50 with type 2 diabetes. That was a change from the original recommendation of 140. So, whether you're 50 or 40, the blood pressure goals are now the same. Hypertension and diabetes together more than double cardiovascular risk compared to either alone. So, get it under control quickly and keep it there. Cholesterol, that's the third pillar. Statins are the foundation here. I know they get a bad rep. They are great drugs. If you're having cramps, it could be the type. Remember, there's some that affect muscle more than others. If you're on a tour of a statin, which is Lipitor, try rosuvastatin. That is Crestor. It is water soluble and less likely to interfere with other drugs and caused those cramps. Organ protected medications. This is where we make incredible strides in the last few years. So, SGLT-2Õs. You've seen Jardines, Invokana was probably the original. These are great for cardiovascular and renal protective effects. Even independent of diabetes now. GLP-1Õs. That is your Trulicity, your Ozempic. There is also the GLP, GIP that is Tripeptide, also known as Munjal. These have great cardiovascular effects as well. Cardioprotective that is.

DR. RAJAY SEUDATH
And now they are also considered first line therapy, too. Before we had to do stepwise. We can go right to them.

DR. JAMES DINN
Yes. Although insurance companies sometimes have their own requirements. For the docs, the FDA and ADA now recommend starting two inhibitors and GLP-1Õs independent of A1C in patients with established ASCVD heart failure or CKD. These are organ protective therapies. First glucose lowering second in these populations. Don't wait for the A1C to be out of range. Start them early and keep them on. Screenings. This is the fifth pillar. Catch it before it catches you. Make sure you're getting your eye exams at least yearly then whatever they recommend after that. Getting your urine screened by your physician. Foot exams, whether it be a podiatrist or your PCP. Then, your nerves should be examined. This is part of the foot exam. It should be done. There's a monofilament. I really don't have a lot of fun facts for this one except the eye screenings are now really easy. They even have AI powered cameras that can screen your eyes for diabetic retinopathy right in your doctor's office most of the time. So, there's no ophthalmologist needed in many cases for the initial screening. So, if you think it's too difficult or time consuming, ask about it. It might be available at your office.

DR. RAJAY SEUDATH
And you don't have to have your eyes dilated for it.

DR. JAMES DINN
No, you don't.

DR. RAJAY SEUDATH
It's super convenient.

CARMENN MILES
Yeah. It's never fun to have your eyes dilated, that's for sure.

DR. JAMES DINN
The last thing I'd like to talk about is lifestyle. That's the foundation for everything. Medical nutrition therapy is something that everyone should be considering. A 500 to 750 calorie deficit. So, for those of you who don't know how to count calories, go to the American Diabetes Association. They can teach you. They have a whole patient library. That 500 to 750 deficit will help you lose a safe 2 to 3 pounds a week. Over time, a 5% weight loss can be majorly useful in controlling all your chronic conditions.

CARMENN MILES
There is so much more to be said on this topic, gentlemen, but I'm looking at our time, and unfortunately, we're out of time today, so we'll have to come back another time and continue this conversation. Thank you both for joining us today. Thank you to our listeners for tuning into this episode of Docs in a Pod presented by WellMed. Complications from diabetes don't happen overnight. They build up slowly. That means we have time to prevent and control them. But this does require that we're paying attention to our bodies, recognizing changes, getting those annual checkups, and bringing our concerns to a trusted medical professional. Don't be a stranger. Subscribe to this podcast so you never miss an episode. If today's show helped you, sharing is caring. Tell your friends and family where to find us on any podcast platform, and you can also catch us on the radio in several Texas markets. Thank you again for listening. Until next time, stay well.

OUTRO
Executive producer for Docs in a Pod is Dan Calderon. The producer is Cherise Pendleton. Thank you for listening to Docs in a Pod presented by WellMed Be sure and listen next week to Docs in a Pod presented by, WellMed.

DISCLAIMER
This transcript is generated using a podcast editing tool; there may be small differences between this transcript and the recorded audio content.

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