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Caitlin Whyte: Welcome to Check-up Chat with EvergreenHealth. I'm Caitlin Whyte. According to the American Diabetes Association, 1.5 million Americans are diagnosed with diabetes each year. I'm joined today by Dr. Andrew Thurman, a physician at EvergreenHealth Primary Care in Monroe to discuss diabetes prevention and management.

Dr. Thurman, it is so great to have you here with us.

Dr. Andrew Thurman: Thanks for having me. I'm excited.

Caitlin Whyte: So before we jump into managing diabetes, could you provide us with some background information? A simple question at first, just what is diabetes?

Dr. Andrew Thurman: Diabetes, essentially it's blood sugars that are too high in the body. It happens most commonly because of inadequate release of insulin from the pancreas. So the low insulin helps to keep blood sugar levels down and in the normal range. Also what happens is, if we get overweight or obese, the fat cells don't respond as well to the insulin that we're making and so they get more resistant to the insulin that the body is producing. And so you could still have some insulin circulating in your body, and it's just not as effective because the cells are larger and they don't respond as well to the insulin that's still there.

For a combination of those reasons, the blood sugars are increased and going around in the blood, basically, which can cause many problems, you know, in several organ systems over time. And that includes developing plaque in the large arteries, which can increase chances for heart attack and stroke. And in other organs, it can also cause issues within the retina of the eye. It can cause some damage in the vessels in the eyes, which can lead division loss or, you know, problems with the vision. It can cause kidney issues as well as nerve problems, loss of sensation in the feet and many other things. So it's not a nice disease process, but there are definitely good options to help keep it under control.

Caitlin Whyte: So then a followup to that, what is the difference between type 1 and type 2 diabetes?

Dr. Andrew Thurman: Type 1 diabetes is an autoimmune issue where the body attacks the pancreas itself and so there's not enough insulin being produced by the pancreas. And we think that this typically happens after like a viral infection and we're not really sure why it happens, but it just seems to be kind of the body's immune response or reaction to a viral infection. And again, that greatly reduces the production of the body's own insulin. And so with less insulin, the sugars run higher and can sometimes get out of control and then people can sometimes get quite ill. And so they often feel pretty crummy and often present to their doctor or the emergency room with, you know, weight loss and hunger and thirst and sometimes dizziness and everything. And that typically happens most commonly in childhood or, you know, adolescents. But we do see some type 1 diabetes also starting or, you know, being found in adulthood, so it's not impossible for adults to have type 1 diabetes, but more common in children and adolescents. And the main treatment for type 1 since they're not producing enough insulin is actually to start insulin for them. They must have insulin to keep their sugars down.

And then type 2 diabetes is characterized, you know, as we were discussing earlier, that's the inadequate insulin production. You know, usually there's some insulin production, but not quite enough. And then also the cells being resistant, relatively resistant to the insulin that is being produced. So the sugars, again, kind of get higher in that instance. And we see that more often in typically in adulthood, although again, there could be some childhood or adolescent type 2 diabetes. I mean, there's a genetic component certainly with that, tends to run in families. Certain populations have higher risks for type two diabetes and that's Native American, Latino populations tend to have a higher incidence of type 2. And then there's some lifestyle issues as well that put you at risk for type 2 diabetes higher. And that's, you know, being less active, being overweight. As we age, we need to need to keep active and try and keep our weight down to reduce our chances of developing type 2 diabetes.

Caitlin Whyte: So what are the risk factors for diabetes? Can it be prevented even though it hits so many demographics?

Dr. Andrew Thurman: Yes. So it can be prevented. And, you know, I've kind of touched on some of the risk factors, you know, again, genetic, race, increased risk with native American and Latino populations. And one of the important things is, you know, as a family physician, seeing people for their annual physicals or, you know, their intermittent physical. You know, if you're young in your 20s and 30s, you don't necessarily need a physical every year, but you should have one every couple of years. And that's a great opportunity for us as providers to screen for diabetes and other health issues, catch people up on their immunizations, that kind of thing.

But one of the things that we do is check a hemoglobin A1c and that's a blood test that shows the average blood sugar in your body over the last three months, basically. So there are normal levels for that, there are pre-diabetic levels for that, and then there's diabetes levels for that test. So that's one of the things where, you know, early recognition, particularly of like prediabetes, which is again elevated sugars, but not to the diabetic range.

If we find someone with prediabetes, we can try and get more aggressive in terms of getting them to exercise, watch the diet monitor their other health parameters, like blood pressure and cholesterol and that kind of thing to help hopefully prevent and then, you know, best delay the progression into diabetes because we know that if those measures are not done, more often than not, they will at some point go into diabetes. It's usually just kind of a matter of time if they're not taking care of themselves and doing the things that they can control to try and help reduce their risk of getting diabetes.

Caitlin Whyte: So knowing all these risk factors, how is diabetes then detected and diagnosed?

Dr. Andrew Thurman: Yeah, that's a great question. And a lot of people don't even realize that they have it, you know. Type 1 diabetes, typically they can be pretty sick when they're diagnosed because they tend to get dehydrated. Their blood sugars are very high sometimes, you know, over 400, 500, 600 sugar levels. And so the body kind of gets very dehydrated and often they're harmony or really feeling ill and, you know, obviously something is wrong and they go to urgent care, their doctor's office, the emergency room, some place and, you know, we see that their sugar is 600, you know, that's a pretty easy way to diagnose it. And that's more common with type 1 diabetes.

With type 2 diabetes, it oftentimes happens gradually over time and so, you know, there's not a sudden change from your sugars running normally in low 100 to the 200 or 300 range that we often see in diabetes. So yeah, a lot of people I see, you know, yeah, maybe mom or dad had diabetes or a sibling might have it, but they didn't really have any symptoms and we check their blood work on a routine exam and, lo and behold, they're in the diabetes range. And so then, you know, we need to talk further about treatments and what they can do to reduce their risk of having complications from the diabetes.

So the most effective way to screen and detect the diabetes early is to, you know, get in and get the blood tests, go and get the hemoglobin A1c, get the fasting blood sugar. There's glucose tolerance tests that we can do as well. I don't tend to do them a lot, but basically you drink this kind of sugary liquid, check your blood sugar before you drink it, and then you drink it and then you wait two hours and then we do another blood sugar and there's normal ranges for where that should be. That's more often done in pregnancy to detect diabetes in pregnancy, but getting in, yeah, go see your primary care provider, get a physical, if you've not had one recently, get some blood work, you know, again, as well as checking your blood pressure, making sure you're up-to-date on your other screenings, mammograms, colonoscopies, pap smears, all that stuff is kind of what we do during a preventive healthcare exam or a physical.

Caitlin Whyte: Let's talk about prediabetes for a moment. Can someone turn that around?

Dr. Andrew Thurman: Yes, absolutely. And that's, you know, really where we try and focus, you know, a lot of our efforts into helping people to turn that around, you know, to get rid of the prediabetes, go back to normal, you know, blood sugar. Oftentimes, we'll have people meet with a dietician or nutritionist to determine foods that are best to do that. And typically, it's trying to avoid sugar-intense foods, you know, the junk foods, you know, the chips and the sweets, particularly around the holidays; this is a challenging time for that. Trying to eat more natural foods, so fruits and vegetables, lean proteins like fish, chicken, that kind of thing, and less of the highly processed foods and the sugary foods, you know, again, the sweets and salty snacks and that kind of thing.

And then exercise is another key component to that. So it's dietary and exercise are kind of the main weapons that we have, main ways to reduce risks. And exercise is recommended to be 150 minutes per week and at least four days a week. And if someone can do seven days a week for 20 minutes or twenty-five minutes, that's awesome. But at least four days a week for 30, 35 minutes is kind of goal for aerobic exercise. And that can be as simple as just a brisk walk. I mean, you don't have to have a gym membership or any fancy machinery, but just going out for a brisk walk, going to the mall and walking around, you know, when it's colder and wetter these days, biking, swimming, you know, whatever someone enjoys doing, I just try and get them to do it. Goal is 150 minutes per week and then working on the diet as well. Those are kind of the key ways to prevent prediabetes from turning into diabetes and also turning around prediabetes back to normal blood sugars. And some people are very motivated. I mean, some people are scared of the diabetes, you know, for good reason. And again, as we talked about, it's really an unpleasant disease process, but some people are just extremely motivated. They can drop five or ten or more pounds and really can improve their blood sugar control.

And it's really as simple as, you know, the studies have shown that if you can lose five pounds, that really makes a big impact on several parameters of your health, including blood sugar control, blood pressure, cholesterol levels, that kind of thing. So it all depends on the person's motivation and, you know, how serious they want to be. And in some cases, you know, it's difficult for someone to exercise, you know, if they have back issues. You know, for a variety of reasons, it can be kind of challenging, but usually we can work on the diet in that case or, you know, try other things too to turn around their numbers and get them healthier.

Caitlin Whyte: Yeah. Well, even if you don't have prediabetes, are there any other things for people to keep in mind in general just to lower the risk?

Dr. Andrew Thurman: Yeah, I think it's, you know, the common sense stuff that we've always heard and known all along. So don't smoke, minimize alcohol intake, drink responsibly if you're going to drink. Generally, that's, you know, two drinks or less per day. Staying active, so, you know, again, goal of 150 minutes of exercise. That's kind of for everybody. And I think that's definitely a good thing to shoot for. You know, again, at least four days a week, total of 150 minutes of aerobic exercise each week.

And then again, the dietary recommendations for prediabetes and diabetes, I think applies to the general population as well. I mean, it's a good idea. More fruits and vegetables, less processed foods, less sugary beverages are a huge issue, you know, and that's not just soda. I mean, that's also, you know, the flavored coffees and mochas and that kind of stuff. Those things have a large amount of sugar in them. And then, you know, occasionally, I tell patients, you don't need to eliminate sugar, you just need to moderate it. Allow yourself to indulge, you know, have a small piece of pie, that kind of thing, especially during the holidays, this time of year. Having the occasional mocha, flavored coffee beverage, tea with sugar, whatever, just don't make it a regular practice. Don't do it every day, but make it kind of a splurge rather than a regular part of your diet and that kind of thing.

And then, you know, the nutritionist talk about kind of eating around the peripheral parts of the grocery stores, so the produce and the dairy on the outsides. And then as you get more into the internal part of the grocery store with, you know, the frozen foods and ice cream, processed snacks and chips and that kind of stuff, that's the stuff you want to do a little bit, quite a bit less of and do more of the nuts and, you know, the salads and the other vegetables and lean proteins like we discussed.

Caitlin Whyte: Now, receiving a diabetes diagnosis can be scary, but there are ways to live a healthy lifestyle while managing it. So doctor, how is diabetes treated? Is there any medication to help regulate your blood sugar?

Dr. Andrew Thurman: Yeah, there's lots of good options these days for managing diabetes and keep people under good control with their blood sugars. I've seen a lot of patients in the past, "Oh, you know, my mom or my grandmother, my grandfather had diabetes. They had to get their foot amputated. You know, they really didn't do well with insulin," these kinds of things. And that really is more of a years ago sort of an issue. We have really good options to treat diabetes these days.

One of the mainstays and the first medications that we reach for is something called metformin. And it's a pill and it helps to reduce blood sugar by helping the liver to reduce sugar output as well as it helps to sensitize our cells to the insulin that we're still making. And it usually is pretty weight neutral, which is nice. You know, trying to avoid medicines that, you know, will cause people to gain weight, but insulin is an option down the line as well and that, you know, some people need to have that, but there's over the last few years have been some exciting new medications that have come out that really help people get better control of their sugars as well as often help with weight loss. A lot of these are advertised on TV now. I see them advertised all the time and kind of get annoyed with them, but it's good that people realize that there are options out there that can help with weight loss and controlling the blood sugars.

We always talked about the lifestyle issues as well. The diet and exercise are kind of key components as well. There's also kind of exciting new ways to check your blood sugar without having to poke your finger every day. So I think there's at least two new devices on the market where basically you kind of have a little needle and you push them into your upper arm or your abdomen, and they usually stay on for two weeks and they can tell you a blood sugar at any time, you know, either with your smartphone or with a little reader. They're pretty amazing. Because, you know, some people who have pretty variable up and down blood sugars have to be testing their blood sugar quite a bit and then we're having to stick their finger and, you know, put the drop of blood on a test strip and see what their sugar was doing. These devices give much more information and, you know, show graphically where your sugars are. And it really helps us as providers as well to determine what medication might be helpful or when are the issues, when are your blood sugars running really high, when are they low, that kind of thing, so we can kind of tailor the treatments to what you're actual situation is. So they've been game changers in that respect.

Caitlin Whyte: And we touched on these a bit already, healthy lifestyle, nutrition, exercise, but just how do these play a role in the management of diabetes?

Dr. Andrew Thurman: They're really important to try and maintain those because once someone is diagnosed -- again, and a lot of people are for good reason, you know, are upset or, you know, they often get depressed when they have diabetes and they feel like a failure and that kind of thing, we don't get into the blame game or, you know, we don't want them to feel that way. Basically, what we want them to do is address the issue that they have. And sometimes it is because of genetic or, you know, cultural, ethnic issues that they're at higher risk for it. You're not a bad person because you have diabetes, but what want to do is try and minimize the risks in the health issues that it will affect in the future and try and get your blood sugars under great control by lifestyle modifications, you know, which is the diet and exercise piece, and then doing some medications if needed to bring the blood sugars down so that you don't get the complications from having the high blood sugars.

But you know, the amputations and, you know, the things from years ago, I have not seen that much at all in my practice. And I don't think it's as common because we have more understanding of screening and, you know, treating diabetes and we have so many more options these days, not just the insulin, you know, that we had 20 years ago, 25 years ago, something like that. We've got a broad array of choices of, you know, pills and injections and monitoring and all sorts of things that are really, you know, it's a totally different experience these days.

And as a primary care provider, I see diabetes every day and I, you know, feel very comfortable managing it, treating it. You know, there are some people who we do send to the specialists, which are called endocrinologists and they specialize in diabetes management. For people who are not able to control their sugars, we send them onto the endocrinologist, typically for type 1 diabetics who often have an insulin pump or, you know, just kind of need more intensive insulin treatment and management, usually we will send those to the endocrinologist as well.

So I'd probably deal with, you know, 85%, 90% of my patients with diabetes. And then that 10% to 15% that are difficult to control or with type 1, I might do refer on to my endocrinologist colleagues.

Caitlin Whyte: And doctor, if someone has concerns about prevention or their existing diabetes, who should they turn to? Where should they start?

Dr. Andrew Thurman: Yeah. I mean, I think I have a bias as a primary care provider, that things should start with their primary care provider and I'll readily admit that, but I think that is a great place to start, you know. And if you don't have a primary care provider, please look up in your area. Evergreen Health Care is where I work and we have a wonderful primary care division with family physicians, internists, pediatricians, large choice of different primary care providers. That's I think the best place to start.

You know, if you're not satisfied with your diabetes care, you know, if you're concerned about diabetes, if you have symptoms that you're worried about, go see your primary care provider. That's what we do. That's kind of why we're there. In addition to lots of other issues that we see, diabetes is one of the most common ones that we see. And so I feel very comfortable managing that and testing for, talking to you through what needs to be done. And again, a lot of people just need either reassurance that they don't have an issue like diabetes or need education about, "Okay. Yeah. This is in the prediabetes level. You know, we need to work on this so that it doesn't advance and put your health at risk for potential complications," but we have great resources. We've got nutritionists we can refer to. Exercise recommendations. We have endocrinologist if you needed monitoring. If you do have diabetes, keeping on top of, you know, getting an annual eye exam is very important to check for early damage in the eye and other screenings and things that we perform as primary care providers.

There's lots of things to monitor, but we're well versed in what to do. And I think that we do it very well. Yeah. I mean, it's just really gratifying to have those patients who are doing really well with their regimens. And again, with these newer agents, it's really helped quite a bit to get people under control who previously had issues with having their blood sugars run high.

And so it's an exciting time and there's lots of options and, yeah, I would just encourage people to definitely get screened. Got people to come in often, "Yeah, I haven't been to the doctor in 15, 20 years. You know, I just wanted to stay latent." And sometimes it can be scary, but you know, we definitely try not to be scary and good just to come in for that physical. And the fear of the unknown is sometimes greater than actually just getting in and getting checked. And it's just a really important part of staying healthy and doing everything you can to live your best and healthiest life.

Caitlin Whyte: Absolutely. Well, thank you so much, Dr. Thurman, for this information and for the care you provide here at EvergreenHealth.

By taking care of yourself each and every day, you can manage your diabetes and live your healthiest best.

Visit evergreenhealth.com/primary-care-physician to find a primary care provider that's right for you. This has been Check-up Chat with EvergreenHealth. I'm Caitlin Whyte. Stay well.