Jaime Lewis (Host): According to the Centers for Disease Control and Prevention, over 37 million Americans have diabetes, and approximately 96 million American adults have pre-diabetes. But there is hope. With proper management and care, people with diabetes can live long, healthy lives. Here for a panel discussion on endocrinology and diabetes management are Dr. Maria Del Mar Morales Hernandez and Dr. Sebastian Urbano Perez-Martinez, both Endocrinologists at Holy Cross Health in Fort Lauderdale. They'll talk about different types of diabetes, hormone regulation, and the latest developments in endocrine treatment. This is Thrive with Holy Cross Health, a production of Holy Cross Health.

I'm Jamie Lewis. Dr. Morales Hernandez and Dr. Perez-Martinez, thank you so much for being here.

Maria del Mar Morales Hernandez, MD: Thank you for having us, Jamie.

Sebastian Urbano Perez-Martinez, MD: Thank you for inviting us.

Host: Let's start with you, Dr. Morales Hernandez. What are the primary differences between Type 1 and Type 2 diabetes and how do these differences affect treatment options.

Maria del Mar Morales Hernandez, MD: Of course. So, the main difference is that Type 1 diabetes is an autoimmune disease. There is a destruction of the beta cells in the pancreas that prohibits or leads to decreased insulin production. So, these patients will be primarily being treated with insulin, because they don't have that capability to produce the insulin when they get to the diagnosis stage.

Now, when we talk about Type 2 diabetes, we are talking about patients that they have a problem with that, how the insulin is working or insulin resistance, and that can lead to a progressive loss of insulin secretion that is going to be lost throughout the time. So these ones we not necessarily will be treating with insulin even though some of them does require that treatment. But it's ones that we're going to be trying to use non-insulin therapies, oral medications or other injectables medications for the diabetes management.

Host: Dr. Perez-Martinez, question for you. How does endocrinology extend beyond diabetes and what other common endocrine disorders should we be aware of?

Sebastian Urbano Perez-Martinez, MD: Great question. It extends a lot beyond diabetes. If we go from top to bottom, we start at the pituitary gland, which is considered the master gland. It secretes a good amount of hormones that regulate the other endocrine glands in the body. After that, we go to the thyroid. Thyroid is very well known, especially nowadays, for the regulation of our metabolism.

Next to the thyroid, we have our parathyroid glands. As we continue to go down, we have our adrenal glands. Those regulate cortisol, mainly, and other hormones. And then once you go down to that, depending on female versus male, you have the ovaries and the testes that produce estrogen and progesterone in women and regulate menstrual cycles, and then testosterone in males.

We also take care of the bones, or the bone density. So that's another big one, especially for the Indian population.

Host: Dr. Morales Hernandez, what are the current guidelines out there right now for screening and diagnosis of diabetes in adults?

Maria del Mar Morales Hernandez, MD: Thank you for this question. I think it's really key that we do a good detection of diabetes, since there's about 4.5 percent of patients are undiagnosed and living with diabetes. So our current guidelines tell us that we should diagnose or screen every adult 35 or older, independent of risk factors.

Now, other patients that should be screened are those with an increased body mass index or overweight or obese with at least one additional risk factor. And those additional risk factors could be an ethnicity that have a higher risk for diabetes, such as Latino Americans, Native Americans, or African Americans.

Also patients with other related metabolic conditions or metabolic syndrome that have low good cholesterol or HDL, that have hypertension. Also patients that during pregnancy developed gestational diabetes or that have an enlarged baby of nine pounds or above for those patients. And other patients that have maybe other endocrinopathies or other type of diabetes related conditions like polycystic ovarian syndrome and severe obesity Now to screen them, we have three tests that we can do. We have plasma glucose that if it's above 126 after eight hours of fastings, it's got good indication for diabetes, and then you will need a secondary confirmatory test. You have the hemoglobin A1c that provides you an average glucose level, so three months.

And when we have it above 6.5, that's indicated of diabetes. And also we have oral glucose tolerance tests that after a 70 gram load of sugar, we measure the sugars in two hours, if it's more than 200, then we have the diagnosis. Now those are the three main tests, but also we can diagnose diabetes when patients with a hyperglycemic crisis, or with a very high sugar, 200 or above, with symptoms of hyperglycemia. And this can be unintentional weight loss, excess thirst, excess hunger. So that's what we call polyphagia and also excess urination, but in large quantity that we call polyuria.

Host: Dr. Perez-Martinez, can you explain the role of hormones in regulating metabolism and weight? This is a topic that so many people are confused about, or think that they understand, but don't actually. And what are the latest treatments available for metabolic disorders?

Sebastian Urbano Perez-Martinez, MD: Good question. Long question. I will try to keep it short. When we talk about metabolism, specifically the weight, we need to keep in mind what can affect how many calories we put in our body. And we can also keep in mind how many calories our body burns in a day. So metabolism specifically refers to how many calories does your body burn or use up just to exist.

So that is the basic metabolic rate. There's nice little formulas out there that you can calculate the basic metabolic rate for anyone. In terms of hormones, the main hormones that we care about, or at least the population cares about, are cortisol and thyroid hormone. Thyroid hormone, as I mentioned previously, is probably the best one that is associated with metabolism, in the sense that if you have either high thyroid hormone levels or low thyroid hormone levels, that can definitely impact your metabolism.

And that will impact your basic metabolic rate; how many calories you burn in a day just by existing. If you have high thyroid hormone levels, you will tend to burn more. And the symptoms that you get with high thyroid hormone levels are usually secondary to that increase basic metabolic rate. So you have a lot of palpitations, you have a lot of anxiety, insomnia, you have diarrhea. If you have the opposite and you have low thyroid hormone levels, then you have all those symptoms in reverse. So you have constipation instead of diarrhea, you have fatigue, you have an additional weight gain instead of weight loss. So when we identify someone with thyroid dysfunction, the first thing to figure out is, what do the labs show? Do the labs correlate with the patient's symptoms? Sometimes they do, sometimes they do not.

When we refer to cortisol, the main thing that people are concerned about is excess cortisol. So this could be an either pathologic increase in cortisol secretion, mainly through the adrenal glands, but it can be due to a lesion in the pituitary gland which controls the adrenal gland.

 When you have increased cortisol that tends to cause a lot of unintentional weight gain pretty fast. It is directly related to stimulating your appetite aggressively. And someone with a stimulated appetite who doesn't really have decreased hunger levels once they eat, then it's very hard to control your weight.

There's also physiologic causes in the secretion of cortisol, as in stress can really increase cortisol sometimes. That is not necessarily pathologic and there's not a medical treatment for that per se, it's mostly managing that stress, but that can also cause similar symptoms. So we have treatments for the pathologic secretion of cortisol, and then we definitely have treatments for the excess thyroid hormone production or the decreased thyroid hormone production.

These are very easily identifiable with laboratory studies. The cortisol is a little bit more tricky. We tend to do what we call dynamic testing in order to evaluate that. And in terms of the research that has kind of given us new ways to keep an eye on these things; there's additional biomarkers that we used to get off-label just to kind of help us out in terms of do we think this excess cortisol is pathologic or not.

But now they have been shown to be very helpful and recommended. And I am talking about the DHAS values. We also tend to get DACTH, which is the hormone that's produced by the pituitary gland, and then cortisol just to kind of give us an idea. But a random cortisol, most of the time it's not diagnostic of either excess or deficiency in cortisol.

Host: It's such a delicate balance. It sounds like one thing begets another, begets another, and just critical to track, I'm sure. Dr. Morales Hernandez, what are some common myths about diabetes management and what are the factual corrections to those misconceptions?

Maria del Mar Morales Hernandez, MD: I really love this question because I think there's a lot of myths out there, and it kind of, then we see it, and it's a challenge we have to face every day in our clinic. So I think one of the first myths is that people think that Type 1 diabetes is a disease or a process only of a young person or that can, is that the one you only can get it if you're young.

If it's an autoimmune disease, clearly autoimmune disease can have onset at any time. So, the actual fact is that you can develop Type 1 diabetes at any time of your life because autoimmune disease can be activated at any time. Now, that's important to know because if we have a patient that have kind of like a phenotype and you're considering like they're not getting control and they were labeled as Type 2 diabetes and you do the screening for Type 1 diabetes, so in those you have to suspect in patients that might have other autoimmune disease or that they might be having a lot of catabolic symptoms, they're very thin and they're not responding with just oral medical therapies; you should screen them for Type 1 diabetes with antibodies, and able detect it and treat it appropriately.

Now I think other myth too is regarding insulin in Type 2 diabetes. A lot of patients see, sort of insulin as a failure of the treatment or they feel that as a failure of themselves. But we have understand the fact is that Type 2 diabetes is a progressive disease.

And even though it can be managed in some occasions with lifestyle and medication, there's a big group of population that will need diabetes through that progressive loss of insulin secretion with time and the disease process. And it should not be seen as a failure, should be seen as an opportunity to help control better their disease and prevent the serious complications that can come from diabetes such as heart disease.

And I would say the third myth of the is thaat diabetes that patients thinks that if they eat a lot of sugar, sometimes I get patients that come to the clinic say, Oh, I got diabetes because I eat a lot of sugar. I think also this is just very like simplification because the actual fact is that we can have patients that eat lot of sugar and never end up having diabetes because it's a multifactorial disease and just getting weight or being overweight is one of the risk factors, but not everybody with overweight and obesity would end up with diabetes because there's genetics and other factors that will take a role in developing the condition.

Host: Good distinction. Dr. Perez-Martinez, what lifestyle changes are recommended? What do you recommend to maintain endocrine health?

Sebastian Urbano Perez-Martinez, MD: So we'll boil it down to probably the most, two most important aspects I think any sort of physician would recommend. That is diet and exercise. It is quite impressive when you see it, which unfortunately is not that common; the change that can happen from a hormonal standpoint in this case, from a diabetes standpoint

in their metabolic profile when they adapt a good diet. So what does a good diet mean in general? Nowadays, it's a very confusing term. You have people who say, well, I don't eat many sweets. I don't eat candy, I don't really drink juice, I eat non GMO, I eat vegan, I eat gluten free, I eat a keto diet. We don't know what of all these things is the healthiest.

Essentially what you want to focus on, and what I tell my patients almost all the time, is that a good diet is comprised of knowing how many calories you burn in a day. And for that you can use your basic metabolic rate and you can have an app to help you. And then saying, all right, I am burning X amount of calories, I need a diet that meets my caloric demands.

And when I do that, when I say I need to eat X amount of calories just to maintain my weight, for example, then you say, all right, we have fats, within the fats we have good fats, we have not so good fats, and then we have bad fats. So ideally you would want to focus on the good fats, avocado for example.

The bad fats, you don't have to think too hard. You look at a food and you say, hmm, there's a very high likelihood that this is not a good fat. So those you would ideally avoid. Can you once in a while indulge in them? Yes, everything in moderation. Then you have your proteins. Protein, I think the more we study about diet, the more we study about exercise, the more important it becomes; in terms of, you need a lot of protein in order to one, when you have a meal, it has more of a satiety effect. Two, it helps to prevent muscle breakdown. It also helps to produce muscle buildup, especially if you have an exercise regimen. And then you go to the carbohydrates. In terms of the carbohydrates, there's a lot of different carbohydrates.

You'd be surprised how many foods are mostly carbohydrates. Which is an interesting discussion with every single patient when they say, I eat a lot of fruit, I eat healthy. And then you say, well, I definitely understand that. A fruit is maybe better than a nice old cheeseburger from McDonald's. However, if you have an underlying issue with sugars, as in someone who has diabetes, ideally you want to limit carbohydrates.

So, when you grab a plate, for example, you say, okay, I am going to have around 50 percent of my plate is going to be protein, then I'm going to eat non starchy vegetables, and then I'm going to have another 25 percent portion which is going to be carbohydrates. That could be rice, pasta, any other type of vegetable.

That could be bread as well. The difficulty nowadays, is that a lot of the foods that we have taste very good, and most of these things that taste very good, they're very calorically dense, and they're mostly carbohydrates. If you had to choose, if you have a meal right in front of you, and you say, well, I want to eat 300 calories, for example; it's going to be a lot healthier for you for those calories to come from a protein source, chicken, for example, than it is for it to come from a Snickers bar, which is also going to be 300 calories.

But then you're not going to have that benefit of eating protein, you're not going to have that benefit of maintaining fullness throughout extended periods of time. All those things kind of together when we think about diet, we need to think of how many calories am I consuming? What are my goals for my weight? Do I want to maintain my weight? Do I want to lose weight? Do I want to gain weight? And then primarily eat protein, which is going to maintain that effect of being full. And then 25 percent carbohydrates and then non starchy vegetables/fats.

In terms of the vegan versus keto versus non GMO, all these different types of miniatures that have been introduced in the past few years, those are fine, but at the end of the day, even if you have the healthiest diet, and you're overeating the amount of calories, then that is going to lead to bad things. So you want to avoid those.

Host: Dr. Morales Hernandez, Is there anything you wanted to add, perhaps, to how, you know, talking about how does diet play a role in managing diabetes? Are there specific dietary patterns that you recommend to your patients?

 Okay.

Maria del Mar Morales Hernandez, MD: Yes, of course. Like, kind of an extension to what Dr. Perez said, I think like we have to emphasize more of like macronutrients and kind of like portion control in our patients. Now, when it comes to diabetes, we do know that having a good alimentation patterns is going to help them control their diabetes and also help prevent hypoglycemia in some of these patients as well.

 When it comes to giving recommendations, normally I, what I do recommend is patients to see a nutritionist or a registered dietician, because many times, and it has been proven that up to 2% improvement on A1C in patients with diabetes when they see one of our colleagues in health to help us to individualize and also help them guide it better in their nutrition.

But in general, the patterns that I do recommend is focusing in micronutrients, controlling the portion of carbohydrate, having whole foods, having lean protein, no dairy fats, and focusing when they do have those carbohydrates to ensure looking that they have good fiber content. And regarding beverage, I think it's very important for patients with diabetes to drink mostly water or to avoid sugary drinks. And if there's inability to do that, then to substitute for the cereals or the diet sodas in those circumstances can help them achieve better control.

So I'm kind of like, we'll go with what he said, more portion controlled and in focusing in lean protein, non starchy vegetables, and having a non fat dairy and healthy fats. That's what I would tell them.

Host: Dr. Perez-Martinez, let's switch gears a little bit and talk about your insights into the latest developments in testosterone replacement therapy for men. What do you have to say about that lately?

Sebastian Urbano Perez-Martinez, MD: Testosterone deficiency in males, we're fortunate enough that it has become a lot more acceptable for males to look for help when they are feeling the symptoms of low testosterone, aka hypogonadism. Testosterone replacement therapy has been around for quite a good amount of time.

As of right now, the most common type of replacement is an intramuscular injection, that is, probably the most commonly prescribed. However, from a patient's standpoint, some people just don't like injecting themselves twice a week or once every two weeks or once every week with a big needle of a highly viscous substance that sometimes it's a little bit uncomfortable.

So the pharmaceuticals very astutely, they decided to come up with new type of regimens that include a subcutaneous shot. This shot is given once a week and it comes in pre filled pens and it is very easy to do. The other ones are pills. So pills for a good amount of time were not as safe. They were not as effective as the intramuscular injections.

But nowadays with the advancements in technology and the pharmaceuticals kind of doing the research, they've been able to come up with oral medications that you take either once or twice a day. And they maintain a very stable testosterone level throughout the day. And that has immense benefits. Because one of the main issues with these injections that we used to do, all the time, was that your testosterone levels would take a few days to go up, and then after they went up, you would feel like you were in the prime, you were just ready to go, and then after that, those levels would start to come down, and down, and down, and down, until at some point they might be even, lower than what you want them to be.

And then at that point, the patients feel quite crummy. So with these new medications, the ones that are a little bit more frequent, you have a decreased risk in these side effects. And then you have an increase in the benefits and the stability and you get better levels throughout the day so that patients feel a lot better throughout the day.

Host: That's a good, future prognosis, it sounds like, for people who, need that treatment. Dr. Morales Hernandez, can you explain how continuous glucose monitoring works and its benefits for diabetes management?

Maria del Mar Morales Hernandez, MD: Of course. So, continuous glucose monitor. So, the sensor goes interstitial fluid. So, it's in the fluid that is between the skin and the muscle, and it's continuously monitoring or providing a glucose reading, and that's through like an oxidase reduction or chemical reaction that's going to translate into a sugar level.

So that has been really important for us endocrinologists and for the patients, especially with Type 1 diabetes, because we can have real time data or right at our hands a constant feedback on how the patient's glucose are. The major role it has the patients is especially for patients with insulin and with high glucose variability or basically a lot of ups and downs and it's going to help you guide better their insulin dosing, also to able to identify hypoglycemia.

That's one of the complications that could happen with insulin. So it's been a really helpful tool preventing and in catching that hypoglycemia prior to become severe. So patients can go ahead and when they see their glucose is down trending and getting to the danger zone, then they can provide some sugar and then they can verify that they go back up.

So it's a lot of safety. Now it also, they're integrating to the insulin pumps, which is have allowed them to be more automatized and a little bit easier for the patients regarding management and also a little bit more physiological.

Host: Dr. Perez-Martinez, what future directions do you see in the future for research and treatment of endocrine disorders?

Sebastian Urbano Perez-Martinez, MD: Close to what we are seeing now. We've already kind of seen some of those advancements. So Dr. Morales Hernandez was just speaking about CGMs. These CGMs, often we have to switch them out every 10 days or every 2 weeks, depending on which one you have. Nowadays there is one that lasts for an entire year that is implantable.

I haven't had the opportunity to use it as of right now, but having something like that where you don't have to switch it that often, or the patient themselves can't do it for whatever reason, then that would be very beneficial. We also have in the works, longer acting insulins. So as of right now, we have what we call long acting insulin or basal insulin.

So these we tend to give every day because they act for around 24 hours. A little bit more than that, but then we have other insulins that have a half life over a week. As of right now, this is not commercially available, but think about the possibility of not having to inject yourself every day, and then you just have to do it once a week, or maybe once a month.

So these are two things from a diabetes standpoint that will probably get more products in the future, and we're kind of starting to see them right now, they're just not really applicable at this time. From other endocrine disorders, I mentioned about the role of metabolism. When we speak about metabolism, we mentioned how cortisol can regulate your appetite, how thyroid can regulate your metabolism.

Another very big, important part of metabolism is your the amount of muscle that you have. As of right now there is all these medications which are GLP1 and GIP agonists essentially that help with the treatment of diabetes and also have additional benefits of reducing insulin resistance and producing weight loss. Now, other pharmaceuticals who really weren't able to have their product available with this GLP1 craze are going to start working on or at least they've already started, on medications that can stimulate the muscle.

Essentially you just have to imagine yourself, is it possible to get the benefits of exercising without actually exercising? It's a very interesting thought and some people are going to agree, some people are going to disagree, but we also have to think about the people who are just unable to exercise.

They have contraindications to being very active, to doing strength training. They're at risk for falls or they have some sort of paralysis. These people will still benefit from the muscle turnover, from the muscle buildup. The muscle itself is an organ, uses a lot of energy. So we have all these medications that are now in the works that they're being studied to treat muscle dystrophies. But I sense that if they are effective, they will be used for other things as well.

Host: That's so interesting. Well, I really appreciate all of your insight, all of your information, thank you for bringing your expertise and bringing it to bear on the future of your field. I really appreciate it.

Sebastian Urbano Perez-Martinez, MD: Thank you for having us.

Maria del Mar Morales Hernandez, MD: Thank you.

Host: That was Dr. Maria Del Mar Morales Hernandez and Dr. Sebastian Urbano Perez-Martinez, endocrinologists at Holy Cross Health in Fort Lauderdale. To schedule an appointment, visit holy-cross.com and thank you for listening to Thrive with Holy Cross Health.