Intro: Duly Noted, a Health and Care podcast is the official podcast series of Duly Health and Care. Each podcast features physicians or team members discussing groundbreaking topics and innovations that help listeners reimagine and better understand an extraordinary health and care experience.

Joey Wahler (Host): The CDC says 37.3 million people or 11% of the US population has it. So we're discussing diabetes and how it's treated. Our guest, Dr. Malcolm Franklin, an Internal Medicine Physician with Duly Health and Care. This is Duly Noted, a Health and Care podcast. Thanks for listening. I'm Joey Wahler. Hi, Dr. Franklin. Thanks for joining us.

Malcolm Bernard Franklin, MD: Hi. Thanks for having me.

Host: Great to have you with us. So first, what exactly for those that don't know, is diabetes and how is it typically diagnosed? Is it tested for during an annual physical exam, for instance?

Malcolm Bernard Franklin, MD: That's correct. So with a typical physical examination, we will run some fasting blood tests, and a fasting blood sugar can be the first indicator that a patient may be dealing with diabetes or pre-diabetes.

Host: And so when we say diabetes, some may sort of know what it is, but specifically what in fact is it?

Malcolm Bernard Franklin, MD: So diabetes is an issue where the body is no longer processing blood sugar, which we refer to as glucose appropriately. People with Type 2 diabetes, the most common form, struggle with elevated blood sugar levels that can lead to complications in the body, as time goes on.

Host: And so speaking of which, if someone has diabetes, what are some common symptoms that someone might experience?

Malcolm Bernard Franklin, MD: Some patients with diabetes will experience symptoms of unexplained weight loss, increased thirst, blurred vision. Some may even experience eating more and yet losing weight.

Host: So what are some of the more common causes and is there anything we can do ourselves to prevent diabetes from occurring?

Malcolm Bernard Franklin, MD: Yes. Diabetes, can certainly be impacted by our lifestyle. So trying to have and maintain a healthy body weight, is a helpful way of limiting the likelihood of developing diabetes. Some patients develop diabetes because of genetic predisposition. So Type 2 diabetes has a strong, family connection where parents who have Type 2 diabetes may pass that gene onto their offspring. And so knowing your family history is also important and helping to balance your risk factors.

Host: Gotcha. So genetics aside. What are some things in our diet that can either contribute to or help fend off getting diabetes?

Malcolm Bernard Franklin, MD: Trying to get a diet rich in fruits and vegetables and water, trying to eliminate sodas and high sugar content products. People think of diabetes and instantly think of the risks associated with desserts, cakes, cookies, pies, but also carbohydrates in general, anything that's made with white flour. So I usually instruct patients to watch for breads, pasta, rice, and potatoes to limit their risk of diabetes.

Host: Interesting rice and potatoes. I wouldn't have thought of that.

Malcolm Bernard Franklin, MD: Yes. So those are common foods and we think of those as a part of a well-balanced meal. But for patients who are struggling with blood sugar issues, lessening their intake of those products can help to decrease their blood sugar levels.

Host: All things being equal Doc, let's say you don't have a predisposition to it genetically; is there a typical age range where someone is more vulnerable to getting diabetes?

Malcolm Bernard Franklin, MD: As we age, the pancreas, the organ in the body that is responsible for making insulin to help us manage blood sugar, the pancreas can become less efficient at producing enough insulin. And most patients that we see are in their thirties or forties, when we begin to see signs of a change in the way that their body is metabolizing or handling sugar.

Host: Let me ask you this. When you mentioned at the top the eye-popping numbers, the whopping numbers of people in this country that have diabetes. We also hear the term pre-diabetic. What does that mean and how many people have that?

Malcolm Bernard Franklin, MD: There's a far greater number of patients with pre-diabetes and with the advent of newer blood tests and screening mechanisms for diabetes; we are seeing more and more patients with pre-diabetes. So pre-diabetes is when your blood sugar levels are higher than normal, but not quite in the diagnostic range to consider it diabetes. Typical fasting blood sugar should be less than 110 milligrams per deciliter. So if a patient comes in for their annual physical and they have a sugar that is 116 or 120, that would place them in a pre-diabetic category. And those are patients that we will typically ask to change their diet and then to, very importantly, try to get more exercise as being sedentary increases our risk of diabetes.

Host: And so if someone is pre-diabetic and they are warned and they do make significant changes in their diet, et cetera, can you then ward off diabetes?

Malcolm Bernard Franklin, MD: Yes you can. And that's a great point. So patients who find out that they are pre-diabetic and heed the necessary warnings and instruction, they can actually reverse or manage that pre-diabetic state without it ever converting into full Type 2 diabetes.

Host: Because once it becomes Type 2 diabetes, then is it simply very difficult or is it impossible to reverse it?

Malcolm Bernard Franklin, MD: Well, it is very difficult to reverse those sugar levels. But the unfortunate piece is that once a patient becomes Type 2 diabetic, they're then considered Type 2 diabetic for the rest of their lives, even if they're able to manage the disease with diet and exercise and no medications. Type 2 diabetes is thought of as a fasting blood sugar of 126 milligrams per deciliter on two separate occasions when the patient is fasted for 10 to 12 hours ahead of time. Once the patient has that diagnosis, even if they can drive those sugar levels down to appropriate levels or ranges that are not in the truly diabetic range, it still would be considered Type 2 diabetes long term.

Host: Gotcha. So you've mentioned Type 1 and Type 2. What's the difference between them and who's at risk for each?

Malcolm Bernard Franklin, MD: Type 1 diabetes is, a problem where there is destruction of the beta cells of the pancreas, which produce insulin. And this one is thought to be more of an autoimmune process where a person's immune system inappropriately recognizes their pancreas as something foreign and it attacks specifically those beta cells which produce insulin. This is the form of diabetes that we typically see in the younger population. So children and adolescents tend to be Type 1 when they develop this issue. It was previously thought that just environmental factors were at play that may have set the immune system into motion to lead to Type 1 diabetes, but now they think that there may be a genetic predisposition in Type 1 as well.

Host: But Type 2, as you pointed out, I believe, is the more common by far of the two.

Malcolm Bernard Franklin, MD: That's exactly right. Type 2 is by far the most common and, a large, risk factor for setting any of us up for Type 2 diabetes is having excess body weight. So people who deal with being overweight or who deal with clinical obesity are more predisposed to Type 2 diabetes.

Host: So after an initial diagnosis of diabetes, when would a primary care physician like yourself refer a patient to a specialist to manage it?

Malcolm Bernard Franklin, MD: For Type 1 diabetics, we'll typically send all of them to an endocrinologist, a specialist to help manage their diabetes because they need insulin as their mainstay of therapy. Type 2 diabetes will typically be able to be managed by the primary care physician as diet and exercise, and then sometimes medications, simply one or two pills may help to balance out the sugar levels. If those patients aren't able to get under control, which we consider to have an A1C of less than 7.0, then we will look to send those patients to see an endocrinologist as well.

Host: And so a primary care doctor, it seems like you're saying, would still be involved in the process ongoing.

Malcolm Bernard Franklin, MD: That's correct.

Host: Couple of other things. So if left untreated, how dangerous can diabetes be?

Malcolm Bernard Franklin, MD: Diabetes can be extremely dangerous. When people hear the term diabetes, they may have some vague understanding of it at some connection to blood sugar, but elevated blood sugar levels in a bloodstream can reap serious benefits on vital organs such as the heart, the kidneys, the eyes; it can also damage the blood vessels that supply the nerves in your feet and hands.

And so people who don't have well-controlled diabetes are at risk for all of these serious complications of what we term neuropathy; nerve damage, and the worst forms can lead to amputation. People with diabetes especially Type 2, have an increased risk for heart disease, heart attacks, strokes, and kidney disease, which can lead to dialysis.

Host: Wow. So all of the above being said, let's talk about treatment. What are the options that are available? What's most common for people with diabetes?

Malcolm Bernard Franklin, MD: So the most common treatment for a patient who's newly diagnosed with diabetes Type 2 would be a medication known as metformin. Metformin is a pill that's been around for years that helps the liver to not produce glucose in excess. Our livers have the ability to break down stored sugar known as glycogen, and to send that to the bloodstream.

Host: And then other than that, are there any other treatments that are more commonly prescribed?

Malcolm Bernard Franklin, MD: There are other medications that we use. So we have pills in addition to the metformin that work on the muscles or that work in the bloodstream to help promote glucose moving into cells. So pills such as JANUVIA, pills such as pioglitazone and then there are newer products out there that are getting a lot of press because they not only help to manage the blood sugar issue, but they can also contribute to significant weight loss for patients with diabetes.

So those are products like Ozempic, Mounjaro, Trulicity, that many patients have heard of and are asking about.

Host: And as you point out, that's become a more common thing for people with diabetes because being overweight and having it are so closely associated. Those weight loss drugs associated with diabetic patients, they really need to be managed properly, right? You don't want people just going off and managing it on their own.

Malcolm Bernard Franklin, MD: That's exactly right. So they definitely need to be under a physician's supervision and to have their levels monitored and as well as their weight loss, and to ensure that the sugar levels are being appropriately treated and not being lowered to a dangerous level.

Host: Right. And so in summary, Doctor, what's your overall message to our listeners about what lifestyle they can expect living with diabetes provided of course that it is managed properly?

Malcolm Bernard Franklin, MD: The good news is diabetes can certainly be something that a patient can live with and continue to have a full life experience. They can still enjoy travel, exercise, time with their family. They just have to be willing to make some better choices when it comes to the food products that they consume and trying to be diligent about exercise and taking whatever medications are prescribed for them.

Host: And ease up on the rice and potatoes.

Malcolm Bernard Franklin, MD: Yes, unfortunately they have to give up on some of the carbs that they've come to know and love.

Host: Oh, that's a killer for me, but I'm going to have to tell my wife. We need to adjust the menu from time to time.

Malcolm Bernard Franklin, MD: Yes, indeed.

Host: Well, folks, we trust you are now more familiar with diabetes and its treatment. Dr. Malcolm Bernard Franklin, thanks so much again.

Malcolm Bernard Franklin, MD: Thank you.

Host: And for more information, please visit dulyhealthandcare.com. Again, that's dulyhealthandcare.com. Now, if you found this podcast helpful, please share it on your social media. I'm Joey Wahler. Thanks again for listening to Duly Noted, a Health and Care podcast. Take care.