Scott Webb (Host): Diabetes is far too common in America. And between the different types and advancements in the diagnosis and treatment of diabetes, it's best to learn from an expert. And my expert guest today is Dr. Milli Jain Gupta. She's a board-certified Endocrinology physician practicing at Franciscan Health, and she's going to explain diabetes and share some of the advancements that are helping folks to live better and manage this chronic disease.

 This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, it's so nice to have you here today. We're going to talk about some of the advancements in diabetes treatment. And it's great to have you here, great to have your expertise, but before we get too far along, in case folks have never seen an endocrinologist, and I know that you're board-certified in Endocrinology, so maybe you could just tell folks what you do, how you do it, approach to care, and all that good stuff.

Dr. Milli Jain Gupta: So when you look for an endocrinologist, you're basically looking for somebody who's going to take care of your endocrine health, which means somebody who deals with the glands in the body that produce hormones. So, the major glands are, you know, the pancreatic gland. Now, the pancreas has multiple functions. The endocrinologist particularly deals with the insulin-producing function, so we deal with diabetes. We do not deal with the digestive aspect of the pancreas that is taken care of by Gastroenterology. We don't take care of the cysts and other kind of tumors in the pancreas, you know.

Then, the other glands that we look at are the pituitary or the adrenal or the ovaries and testicles. We also take care of the thyroid gland. One other aspect of endocrine health is osteoporosis or bone health. So, it's not a gland, but we do take care of osteoporosis. I do want to mention that sometimes patients come in looking for like an all-hormone panel or to just get all their hormones tested. So, there is no such thing. There's no way of testing all your hormones, there's no list. It's a case by case basis, which organ or which gland needs to be investigated.

Also, there are some watershed areas such as menopause, which could be sometimes managed more by OB-GYNs. So, I mean, when you see a general endocrinologist, you would get somebody who specializes in these particular hormones, like I mentioned. But now, an individual endocrinologist could have a special focus on any one of these things.

Host: Right. Today, we're going to focus on diabetes and I know you've got pre-diabetes, type 1, type 2. I want to have you, from your perspective, you know, really as an expert who does this on a daily basis, just explain what diabetes is and sort of go through the different types.

Dr. Milli Jain Gupta: So, diabetes is basically a disease of a group of cells in the tail of the pancreas. They have a fancy name called the islet of Langerhans, and the cells in there particularly that produce insulin are called beta cells. And there are different types of problems with those beta cells that lead to different types of diabetes. And we'll go later into how it is diagnosed, but essentially you would say there are two types of diabetes. One is where all these beta cells, they die all of a sudden because of immune attack, you know, very early in life. So, very early, meaning either in childhood or teenage or even like early years of adulthood. And that's usually type 1 diabetes. With type 2 diabetes, these cells slowly die over the course of a lifetime. And usually, diabetes is diagnosed in the later half of life, you know, in adults, so that's typically type 2.

Then, there is a thing as pre-diabetes. So, you know, later when we talk about the diagnostic criteria, somebody who's not quite there, but a little higher than the normal values in terms of blood glucose, then they are labeled as pre-diabetic or kind of borderline. And the value in catching it there is that you could slow the march towards diabetes or prevent the march towards diabetes with some changes or with maybe just some medications. And there's not too many things out there, but mostly lifestyle changes.

And one other type of diabetes I would mention is gestational diabetes, which is diagnosed in pregnant women. And that is also very important because it has a bearing upon the child, you know, the baby could have congenital malformations. Also, the mother, if she has gestational diabetes, she has a 50% higher risk of developing regular type 2 diabetes later in life. So, all of that needs to be caught in time and treated, and there's value in that.

Host: Yeah. Value of, course. Early diagnosis, you know, with most things in medicine obviously is helpful and beneficial, sometimes life-saving in some cases. Are there any signs and symptoms of diabetes, Doctor? Like does someone just know, or does it really need to be diagnosed, you know, by an expert or by an endocrinologist?

Dr. Milli Jain Gupta: Diabetes is essentially a silent process, and people cannot feel their sugars being high or low unless they are too high or too low. However, there are some signs of uncontrolled diabetes which people may not realize until they it checked. So if somebody is very thirsty, like excessively thirsty all the time, we call it polydipsia. If somebody is using the restroom a lot to urinate, it's called polyuria. And if somebody is very hungry all the time, it's called polyphagia. So if you suddenly spot a change in somebody's behavior, they're drinking a lot of water, they're running to the bathroom, they're eating a lot, and they're losing a lot of weight in spite of all of this, they're looking like they're losing mass in their arms and legs, and they're just getting skinnier, sometimes initially people feel it's a good thing they're losing weight, but then this is one of the bad reasons to lose weight. You know, uncontrolled diabetes can lead to weight loss because you lose all the muscle mass.

 One other interesting early sign could be like a black velvety rash at the back of the neck, or sometimes on the face. It's called acanthosis nigricans. And a lot of people develop that usually on the nape of the neck or somewhere on the neck. And people sometimes feel it's like dry skin or they need to scrub it while taking a shower or something, but it just doesn't go away. It's like a thickened skin that's dark in color. And that's a sign of insulin resistance. Skin tags are also sometimes associated with a risk for diabetes.

Host: You teased earlier that we're going to talk about diagnosis. So, let's do that. How is diabetes diagnosed? What's sort of, if you will, the natural course of the disease?

Dr. Milli Jain Gupta: Diagnosis of diabetes is essentially with a blood test. And all the symptoms that we mentioned, they are not definitive, as in somebody could be feeling those things due to other reasons, just like, you know, feeling tired or losing weight. It could be from so many reasons, you know, but those are just signs. So for diagnosis, we check the blood levels of sugar at certain times. So if we check it in the morning before somebody has had their coffee or breakfast or anything, it's called fasting blood glucose. And usually, there is a cutoff of like 126 or more. That is diabetes.

If it is not quite 126, but above a hundred, like between a hundred to 126, that's prediabetes. So, we have some cut offs in terms of numbers. There's another type of blood sugar that can be checked that's called random. So, it doesn't depend on whether you've eaten or not. But if that sugar value is more than 200, then that is a diagnosis of diabetes. Also, there is a better marker called hemoglobin A1c, which is an average of your blood sugars over three months. And this is the one we use a lot actually in clinical practice. And that number needs to be 6.5 or higher to be diagnosed as diabetes. Between 5.7 to 6.5 is prediabetes. And less than 5.7 is normal. So when we have patients in the office, sometimes they don't rely so much on their fasting or random or whatever reasons, but the A1c is usually very reliable because it's an average over three months. It doesn't depend on what you ate. You know, if somebody says, "I just had a cookie" or something like that, it doesn't depend on that. It depends on what the sugar levels are floating in the levels that have been in the blood, the sugar that's floating in the blood for the last three months, the average levels. That is basically the blood test or blood values that we look at.

Now, talking about the natural course of this disease. So like we said, the natural course, it depends on the lifespan of the beta cells. We are all born with a fixed number or a fixed amount of these cells, and slowly these cells start dying. We're talking about type 2 diabetes, they die slowly, because in type 1 diabetes, remember, they die altogether, all of a sudden, and the person needs insulin right away.

But with type 2 diabetes, the cells start dying slowly, with time, and of course, the cells that die, they don't come back to life. So, there's nothing we can do about that. But initially, you know, we make changes in our lifestyle, then we start some oral medications, and then becomes a point where enough number of cells have died, the person needs a little bit of insulin. And at some point, they might even become insulin dependent. So, it just depends how the cells will fare, you know, in a particular person's pancreas. And this is determined sort of 50% in a genetic way and 50% depending on environmental factors, which means whatever has happened to our bodies in our lifetime, our lifestyle or whatever kind of problems we've had with our health or other habits, you know, smoking, drinking, other environmental factors, lifestyle factors. So even with type 2, it's 50% genetic, 50% based on environmental factors that have affected our bodies. That's the course of type 1 versus type 2 diabetes in a nutshell.

Host: So doctor, when you think about the treatment options, how is diabetes treated and what are some of the advancements?

Dr. Milli Jain Gupta: So, the treatment of diabetes, you know, I would say, there are two buckets, one is lifestyle changes and the other one is the treatment agents or medications that we start the person on.

So, the first thing I would talk about is lifestyle changes. Lifestyle changes are key and they, you could say, 50% depend on that. Some people don't believe in lifestyle changes and some people believe almost too much in lifestyle changes, and they think if they change their diet and start exercising they will be able to cure diabetes completely. Both are not true. Lifestyle change has its place, it has its important place, but sometimes you need a little bit more.

 In terms of medications, for type 1 diabetics, we put them on insulin right away. And there is no oral medication, there is no lifestyle change that can help type 1 diabetics to kind of avoid insulin. So, that is just a fact. Because sometimes, you know, people hear wrong advice that, okay, even with type 1, I mean, if you lose weight or if you eat better or something, you don't need medication, that's not true. And that can be life-threatening for type 1 diabetics if they don't take insulin. For type 2 diabetics, yes, insulin can be avoided for a long time. We start out with oral medications, you know, the first line agents are usually like metformin or there is a sulfonylurea group where we have glipizide and glimepiride and these type of medications. Then, there is a medication called Jardiance that is a relatively newer one that has some additional benefits other than helping with diabetes. It is good for the heart, it is good for the kidneys. So, a new player in our toolbox. Then, there is a medication called Januvia. And, of course, these names kind of represent their whole class of medication, their other options, their other brand names. Your pancreas is like a tired horse with diabetes and you're trying to flag it with medication. So these oral medications are kind of able to tell the pancreas to somehow work and meet the deadline. The lifestyle changes help to kind of say reduce weight or reduce the demand on the pancreas because if somebody is eating a lot of sugar or they're very overweight or obese, then the pancreas would have to work harder, and it's going to be harder for this tired horse to reach its target, you know, reach its deadline.

So if you reduce the target, or if you flag the horse with these oral medications, they are sometimes able to meet the goals. So, that's like an analogy of how these medications are working. But there comes a point where it's a tired horse and you cannot flag it anymore. And then, you need a little bit of insulin. So basically, if insulin is not being produced enough by the pancreas, then you need it in the form of a shot. And we start out with maybe one shot a day, which is a long-acting insulin. And then, there also comes a point where you need a short-acting insulin with each meal.

So typically, full blown diabetes in its advanced stages would need a long-acting insulin and a short-acting insulin with multiple shots in the day. And I know that sounds daunting, but there is a way of getting all of that in and things have come along in terms of diabetes management. I mean, insulin is one of the oldest medications that was discovered and it has come a long way. The types of insulin, the way of delivery of insulins has become more and more user-friendly. And not to say it's an easy transition in anybody's mind to start insulin, but we really help them. And there is an easy way of doing it because, I mean, even with type 1 diabetes, there are children, they're very young teenagers or, you know, young adults who are on insulin and they're able to manage that with all their school and other activities. So, there are tools to help people inculcate these things in their lifestyle if that is the case, you know, if they do get diagnosed with diabetes.

Host: Sure. And Doctor, I know managing diabetes has come a long way. My grandfather had diabetes in the '70s, and it seemed entirely unpleasant. And I'm not saying it's easy today, but maybe a little bit easier. So, take us through some of the advancements in folks checking their blood sugars, giving themselves shots, all that good stuff.

Dr. Milli Jain Gupta: So, the advancements in diabetes have been regarding a few aspects of diabetes care. One is how we measure the glucose. So traditionally, you know, there is a glucometer and there are strips in it, and there are lancets and you have to poke your finger to get a drop of blood and check the glucose. And the patient has to do that multiple times a day to know their sugar. And if they want to know more about the sugar, they have to poke as many times, which is not convenient or, you know, sometimes people start developing calluses in the fingers. Sometimes they feel like it hurts them too much. But that is still the gold standard.

However, now we have continuous glucose monitors where you have like a small disc that could be attached to the arm or the abdomen or any surface on the body where you're not going to sleep over it or you're not going to rip it off easily. And that stays on for a few days. And they check your sugar every few minutes without you having to poke your finger. So, it's just opened up a new world basically for diabetics to have more quality of life basically and more control on what's going on with their sugars. And also, it's more visibility for them to know because sometimes they don't know what's going on and they're just kind of going through the motions.

 The second advancement I would say is in the realm of weight loss medications. So in the last few decades, I think these have been the most revolutionary medications that have come about. We're talking about the GLP-1s. So basically, these include, you know, your popular brand names of Ozempic and Mounjaro and Trulicity. They work on the body in a way that no other medication have so far. I mean, so far, all weight loss medications, basically, they used to have a lot of rebound weight gain and they would be just temporary measures. These medications, the newer ones, they are injectable medications. They're not insulins. They're taken once a week. They resemble a hormone that the body already produces and they work on receptors in the body to reduce craving for food in the mind. They reduce snacking. They reduce portion size with their meals. So basically, they really help people limit their food intake, but it's not like an appetite suppressant completely. It doesn't harm the body in any way. I mean, you'll hear many things on the TV and ads and everything, but they're very physiologic, you know. And of course, you have to find the right patient.

There are some contraindications like we don't give it to people who've had recurrent pancreatitis episodes. We don't give it to people who are planning pregnancies. We don't give it to people who have had medullary thyroid cancer themselves or anywhere in their family tree or family history of it. But other than that, they're pretty safe. Of course, some people could have a little intolerance to them, nausea or gut-related side effects, just like with any other medication. But they can work very well in the right person, in the right patient. So, I think these have brought about a lot of hope and a lot of change, because sometimes losing weight could change around a person's whole life, not just cosmetically, but, you know, in terms of health and all the cardiovascular risk factors they have.

Host: For sure.

Dr. Milli Jain Gupta: The third thing I would say the realm in which there's been major advancement is better types of insulins, you know. So, we used to back in the day have pig insulin and all bovine insulin and other kinds of things. Now, we have all recombinant insulins and better types of insulins that don't have allergic reactions. They have better profile in terms of when they kick in and how long they last in the body and all of that. And also, better insulin delivery systems, so the pens in which we get the insulin these days, these are better than, you know, filling up syringes and putting on ice packs, because it's hard to travel, it's hard to carry them everywhere with you, and you have to manage your life around your insulin regimen in the day.

But nowadays, they come in the form of pens, which are very user-friendly. And you know, once you take the pen out of the fridge, it can stay out of the fridge at room temperature for about a whole month. I mean, you have to discard it after a month, but as long as you don't leave it in a freezing car or near a hot furnace or something like that, it could stay at room temperature for a whole month. It could go with you wherever you go.

Then, we have insulin pumps. An insulin pump is just a device that is filled with insulin. And there are some formulas fed into it. So, it's going to give you insulin every minute. And you'll still have to kind of tell the pump a few things, like when you eat and how much you eat, and you'll have to kind of be on top of what the pump is doing. So, these are basically the advancements in the realm of measuring sugars, managing diabetes with newer medications, and the traditional treatment for diabetes has always been insulin, but there are better insulins and better delivery systems for insulins available now.

Host: Doctor, this has been good stuff today. A lot of great information, a lot of advancements in the diagnosis and treatment of diabetes. Just for those that are newly diagnosed, I know it can be really overwhelming. Maybe you can just briefly share what's the most important tool, in your opinion, in terms of diabetes management.

Dr. Milli Jain Gupta: As an endocrinologist, I would say, I think the most important thing that goes a long way is acceptance versus denial in the patient's mind. So, there are some patients who would be in denial for many, many years, and they wouldn't do anything about diabetes versus if you are able to bring about early acceptance of this chronic illness, so we always tell them it is a chronic illness, it is not something curable, but we can definitely keep it under control. It is not like an infection that would go away. There is nothing to reverse it, but yes, I mean, you could reverse your numbers in terms of getting them under control. So, acceptance, I think, is a very good first attitude towards new diagnosis of any health condition, specifically diabetes, because it's a lifelong process. So when they accept it, they own their own disease, they own the whole journey with treatment. And they make the lifestyle changes, they go ahead with the medications. They need to talk to their doctor about, you know, what would work and clarifying any myths.

And coming to that, I would say that the one important thing would be staying off the supplement market and Google to kind of check everything. But being in good conversation with your doctor and bringing up any questions, any information that you get from friends or relatives or family about all the things that, you know, kind of float around about diabetes. So, I would say a very good rapport with your doctor at accepting the new diagnosis of a chronic illness that's going to be lifelong that would need lifestyle changes and medications would be the best tool for a new diabetic.

Host: Well, that's perfect. I really appreciate your time today, your expertise. It's a lot of information, a lot to take in, but good that we have experts like yourself. Folks, of course, need to speak with their own providers, get referrals if necessary and so forth. But thank you so much for your time.

Dr. Milli Jain Gupta: Thank you.

Host: And for more information, go to franciscanhealth.org and search diabetes. And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.