Disclaimer: This podcast is for informational purposes only and is not intended to be used as personalized medical advice.

Maggie McKay (Host): Type 2 diabetes is on the rise. So if you're diagnosed with it, how do you manage it? Dr. Matthew Rosner, Endocrinologist at Skagit Regional Health is our guest today to tell us what we need to know.

Welcome to Be Well with Skagit Regional Health. I'm your host, Maggie MacKay. Welcome, Dr. Rosner. So great to have you here. I am so interested to hear more about type 2 diabetes because it is something so many people have. What is type 2 diabetes, just to start with?

Matthew Rosner, DO: Type 2 diabetes is a chronic disorder that leads to high blood sugars, hyperglycemia and it's mostly a result of the body's inability to use insulin or using insulin in a reduced capacity due to insulin resistance. Insulin is a hormone produced by the pancreas, which helps to regulate type 2 diabetes. And the reason we care so much is that diabetes has been on the rise for the last several years. The International Diabetes Federation estimated that about one in 11 adults, aged 20 to 79, had diabetes in 2015. This number is only projected to grow by 2040 with estimated 642 million people with type 2 diabetes.

The burden of this disease comes to rest heavily on families and communities and also obviously impacts overall people's health in terms of cardiovascular mortality, kidney disease and other microvascular complications. And just so our guests know, even though there are other types of diabetes, type 1 and gestational, type 2 diabetes accounts are nearly 90% of this. And so most of the focus that we're going to be talking about today will be on type 2 diabetes because of its increasing prevalence and all the comorbidities associated with it.

Maggie McKay (Host): You mentioned type 1 and gestational diabetes. How do those differ from type 2?

Matthew Rosner, DO: So, type 2 diabetes is predominantly influenced mostly by lifestyle factors, physical activity, genetics and also tends to run in the family. It usually is onset at about adulthood, although it can occur in any age and we're seeing a rising incidence and prevalence in children as well. Type 1 diabetes is an autoimmune disease, where the body attacks and destroys insulin-producing beta cells in the pancreas. It usually is diagnosed in childhood or adolescence, although it can occur at any age. People with type 1 diabetes have little to no insulin production and are insulin-dependent for the remainder of their lives. While type 2 diabetes has some great medications and some new innovations out there, adult early-onset or prediabetes can also be treated with lifestyle modifications as well. When you compare that to gestational diabetes, that occurs during pregnancy and as a result of hormonal changes that are responsible for insulin resistance, it's typically not permanent and resolves after childbirth, although it is an early indicator for type 2 diabetes.

Maggie McKay (Host): So, you mentioned lifestyle. What causes type 2 diabetes and when can it develop during a person's life?

Matthew Rosner, DO: You have to look at the pathophysiology of type 2 diabetes. Typically, it occurs in the fifth generation of life or leading into the sixth generation. When there's a lack of insulin secretion, insulin resistance, where the insulin and insulin-sensitive tissues such as liver muscle and fat produce insulin resistance. And in that fashion, leads to decreased insulin, increasing abnormal glucose and then, ultimately, insulin resistance and decreased glucose uptake in muscles and fat tissue. This beta cell dysregulation leads to decreased, reduced insulin release, which causes sustained high blood sugars. That's more the pathogenesis.

In terms of the lifestyle factors, the prevalence of type 2 diabetes directly parallels the rise of obesity. If you look at developing countries, their increase in obesity directly parallels that of type 2 diabetes, such as China and India and other Asian countries that are also developing. Obesity tends to be the number one factor in this, excess fat. A high BMI is the single strongest risk factor for type 2 diabetes It is also associated with many other metabolic abnormalities such as insulin resistance and cardiovascular disease. Other factors that impact this are diet as well, which directly correlates with obesity. But if you look at the availability of high-calorie, high-fat foods and their accessibility, I mean, the access to this has increased substantially over the last hundred years, also, again, parallels to the rise of type 2 diabetes. And although those are the most predominant factors, there are also genetic factors as well or you can see this running in the family. And over the past decade, people with type 2 diabetes have been associated genetically and they found over a hundred robust association signals or genetic signals that directly lead to this. And so, it's a multifactorial approach that causes type 2 diabetes but mostly is a response to obesity and insulin resistance associated with aging as well.

Maggie McKay (Host): And so if you think you might have type 2 diabetes, what are some of the signs or symptoms?

Matthew Rosner, DO: They would include increased thirst called polydipsia. It's a common early symptom of type 2 diabetes. As blood glucose rises, the body tries to dilute the glucose and also draws more water into the tissues which leads to increased thirst. This in turn leads to increased urination as well. And so, frequently, undiagnosed type 2 diabetics go to the bathroom as frequently as every 20 or 30 minutes.

You also are going to have increased hunger due to the inability to utilize your body's own blood glucose. And so, these people may feel hungry all the time and will likely have increased appetite. Despite this increased appetite in food, some people with type 2 diabetes actually have unintended weight loss. And a lot of people will lose 20, 30, 40 pounds before they're diagnosed because their body's unable to utilize their glucose properly.

And so when you take all of this in conjunction together, increased thirst, increased urination, weight loss it really points to this diagnosis. And then, on top of that, since you're unable to metabolize your body's sugar, you have profound fatigue and weakness as well. You have changes in your vision, including blurred vision. These high glucose levels cause fluid to be pulled from the lenses of the eyes, which leads people to have problems focusing, leading to blurred vision. So again, if you're an older individual who has a higher BMI, you might notice these things as well as blurred vision, blurred vision and problems driving, which is a lot of people that I see in my clinic have new-onset problems driving.

They can also have various impacts on their wound healing as well. The high glucose prevents blood vessel flow and impairs the function of the immune system. And so, you'll see people who have type 2 diabetes have an inability to heal with their cuts and wounds as well as skin changes that can occur on their lower extremities or their legs as well. Many people, you can see this in the community, you can see people with these brown pigmentations or darkening of their skin on their shins, and that's a sign of insulin resistance and uncontrolled diabetes as well. In conjunction with this, people also have a kind of tingling or numbness called diabetic neuropathy, which can affect their walking and their balance as well. It can also cause a tremendous amount of pain starting in the feet and usually rise ascending in what we call a stocking-glove distribution where the neuropathy rises symmetrically on both legs.

There are a lot of different things that can point you toward type 2 diabetes. And looking separately, a clinician might not realize this, but taken in conjunction points to this diagnosis as well. Not only are there effects on going to the bathroom, but there will be physical effects as well as effects on people's moods and overall energy. And these people need to be treated very quickly.

Maggie McKay (Host): And Dr. Rosner, once you are diagnosed with type 2 diabetes, what are the major risk factors?

Matthew Rosner, DO: Sure. So, the major risk factors are obesity, having a BMI greater than 25; abdominal obesity as well, waist to hip ratio; having weight gain since young adulthood, which we see more commonly as another independent risk factor of type 2 diabetes, as well as having gestational diabetes is an early indicator that these people need to be screened for type 2 diabetes as well. Different races as well and different ethnicities have different varying factors. Asians typically have a much lower BMI criteria to be screened for type 2 diabetes, whereas in this country, it's a BMI of 25. For Asian individuals, it happens to be 23. Other risk factors as well, are our diet, people who are eating high-calorie processed foods and foods high in fat. Foods high in carbohydrates are more likely to have that abdominal adiposity and obesity, which also is an early indicator of type 2 diabetes.

interestingly enough as well children who have varying weight changes early in their lives they have gained a lot of weight early are more likely to develop type 2 diabetes or having obesity as a child is also an early indicator of this as well.

Maggie McKay (Host): So, the big question, is there a cure for type 2 diabetes?

Matthew Rosner, DO: Currently, there is no cure, which is rather unfortunate. However, there have been some great treatments for type 2 diabetes that have come out in the last couple of years, which also have helped give you cardiac and renal protection, as well as encouraging weight loss. And while there's no cure, the condition can be managed effectively through lifestyle changes, medication and, in some cases, if things get progressively worse, insulin therapy.

And so the goal is to control blood glucose within a target range, so that these people don't have complications and also improve their quality of life. Lifestyle changes, which are adopting a healthy diet such as the Mediterranean or DASH diet; engaging in regular physical activity, about 150 minutes on average a week, recommended by the American Diabetes Association; and maintaining a healthy weight all play a very significant role in managing this condition. But unfortunately, as of right now, there is no official cure to type 2 diabetes.

Maggie McKay (Host): And if you've been diagnosed with type 2 diabetes, what steps should you take to manage your blood sugar and overall health? What should you be doing?

Matthew Rosner, DO: That's a great question. The treatment goals and this is from the Diabetes Prevention Study, which is a large long-term study that looked at preventing overt diabetes and prediabetes. And so, the treatment goals in this study were a weight reduction of at least 5%, specific dietary modifications having total fat and saturated fat less than 30% and 10% of total calories, having a dietary fiber intake of 15 grams and at least four hours per week of physical activity. Again, American Diabetes suggests about 150 minutes a week. These visits as well should be in conjunction with an endocrinologist, as well as a diabetes educator, nutritionist and, if financially permissible, supervised gym sessions with physical trainers.

In this study, they looked at all of these things that I suggested. And that after seven years after the study was conducted, there was a 43% reduction of new-onset type 2 diabetes. And after nine years, there was a 38% reduction in type 2 diabetes. So, these things really work. And this is what I really try to stress to my patients that lifestyle modifications, especially at the early onset, help to mitigate a lot of the damage from type 2 diabetes.

Maggie McKay (Host): How often should a person with diabetes visit their primary care provider?

Matthew Rosner, DO: The American Diabetes Association recommends three to six-month visits with an endocrinologist, as well in conjunction with, again, a nutritionist or diabetic educator, who are parcel for nailing down the nitty-gritty of regular blood sugar monitoring, regular physical activity and also offering diabetes education and support as well as psychosocial support. Diabetes has a large burden on families, has a large burden on the patient in terms of how much medication and how much they're doing. So, any additional support can really help these people quite a bit.

Maggie McKay (Host): Is it reversible?

Matthew Rosner, DO: Reversible is an interesting term. I wouldn't necessarily call it reversible as so much as reducing some of the risk factors. I mean, certainly, diabetes is defined as having an A1c greater than 6. 5. And prediabetes is considered having an A1c greater than 5.7. These studies, the Diabetes Prevention Program, which has been a long-term study, has shown that if you want to call it reversible, you certainly can, but to reduce these risk factors that are causing insulin resistance and lack of insulin production, that includes following a balanced diet, monitoring your carbohydrate intake, controlling your portion sizes, regular physical activity and aiming for at least 150 minutes a week, as well as regular blood sugar monitoring. And that helps to keep a patient aware of how they're doing and how their medications are working, how their lifestyle interventions are working. These patients more importantly aim for a healthy weight. Even if you're overweight, just a modest weight loss of about 3-5% can significantly improve blood glucose control and reduce the risk of complications.

Maggie McKay (Host): Dr. Rosner, with an increase in obesity in children leading to more cases of type 2 diabetes in younger people, what advice do you have for families to help prevent their kids from getting type 2 diabetes?

Matthew Rosner, DO: That's a great question, especially because type 2 diabetes in children is an epidemic that's affecting the world all over. Just in the USA alone, the prevalence of type 2 diabetes increased by almost 31% between 2001 and 2009 and has increased about 5% annually between 2002 and 2012. And obviously, this disproportionately affects people of poor economic status and as well as, unfortunately, people who don't have access to healthcare in this country.

The things that parents can do to help their children prevent this was that the United States Preventive Task Force recommended a whole criteria of guidelines in 2010. This included offering moderate to intense exercises 25 hours or more. The US Preventive Task Force recommended moderate to intense exercise, increasing physical activity, as well as behavioral childhood obesity treatments. And fortunately, medications can often be substituted with some of this as well, including some of the new GLP-1 receptor agonists, as well as Orlistat, which has been proven to help prevent the approach of type 2 diabetes in children.

It starts with the family and also with their relations to the community. There've been a number of approaches for treating these people and most of them revolve around family-based lifestyle interventions, as well as interventions in school as well and interventions in their own community as well. There've been a lot of support groups and interventions within schools to help children prevent type 2 diabetes. And, when people see their peers and their families being supportive of them and also participating in these activities, it really helps.

It also starts with a balanced diet, a diet that has fruits, vegetables, whole grains and lean proteins, as well as low-fat dairy products. Limiting sugar beverages, processed food and high-calorie snacks is a must for children. The accessibility of this has increased in the last 50 years. And you again, see a parallel with the increase in processed foods and fast foods and the amount that people go out to eat and the incidence of type 2 diabetes.

Children are encouraged to at least perform 60 minutes of physical activity on most days of the week, at least five days a week, which sounds like a lot for an adult. But for children, they really need to be doing this, especially if they're at risk and have an elevated BMI. And if you can take this in conjunction with their school activities and their physical activities outside of school, they really should be encouraged to do this, not in an organized way, but in a way that can be fun for them, playing sports, riding bikes, dancing or just being outdoors and having a good time with their friends.

Parents as well need to have a part in this and limit the amount of time that children spend on screens, TVs, computers and phones. The incidence of availability of smartphones and portable mobile devices that provide entertainment again parallels the rise of type 2 diabetes. And it's not surprising because these people are not performing physical activity nearly at a level that they need to be. But also again, it starts with the family fostering a culture of good eating, good healthy lifestyle, getting more physical activity so that it's not a chore for the child, but that it's fun for everybody and they don't feel like they're being singled out.

Maggie McKay (Host): In closing, is there a diabetes education program available locally? And if so, what are the benefits of taking part in such a program?

Matthew Rosner, DO: So, there is diabetes education support over at Skagit. We have a wonderful team of several diabetic educators as well as several nutritionists. There are multiple benefits to seeing these people. They work collaboratively with people on diabetes to provide specific guidance and support for people and try to hone in on their problem areas. Some of the key benefits of seeing a diabetic educator is increased education. A lot of patients that have type 2 diabetes have been poorly educated about what a proper diet is, what's suggested in terms of physical activity and also about recognizing signs and symptoms and treatment options that are available to them.

Diabetes educators also hopefully will empower their patients to take control over their life and give them better self-management skills, including blood glucose monitoring, healthy eating, physical activity and, more importantly, stress management. It also gives them personalized care, that's specific to their needs, such as their age, their health status and cultural background.

Also at Skagit, in conjunction with our diabetes educator, we have electrophysiologists and exercise programs that they refer out to. So, we take a holistic approach to our patients so that they're not just seeing myself as a physician and being offered medications in a very cursory view of lifestyle interventions, but they can hammer this home with a diabetes educator and nutritionist, as well as some of our other support over at Skagit.

Maggie McKay (Host): Thank you so much. We appreciate you informing us on this topic that's so crucial to so many people and helping us figure out how to manage type 2 diabetes if you are diagnosed with it.

Matthew Rosner, DO: That's my pleasure.

Maggie McKay (Host): Again, that's Dr. Matthew Rosner. And if you'd like to learn more, please visit SkagitRegionalHealth.org. That's SkagitRegionalHealth.org. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. This is Be Well with Skagit Regional Health. Thank you for listening.