Share ThisIn our Ask a Doc series, we sit down with physicians and other clinical experts, including those at Allegheny Health Network (AHN), for a chat on an important health topic. In this post, we discuss type 2 diabetes with Patricia Bononi, MD, endocrinologist at AHN.
Diabetes is a chronic, progressive disease that affects more than 38 million Americans and is among the nation's top causes of death. Another 98 million Americans have prediabetes, a serious health condition that often leads to diabetes and can contribute to other health problems.
There are three main types of diabetes. Type 1 diabetes occurs when the pancreas doesn't make enough insulin to control blood sugar levels. Type 2 diabetes accounts for about 95% of people with diabetes. In type 2, insulin resistance is the main problem, with not enough insulin in the body to overcome the resistance. When this happens as part of changes during pregnancy, it’s known as gestational diabetes. About half of women with gestational diabetes go on to develop type 2 diabetes.
With over thirty years of practicing medicine, Patricia Bononi, MD, an endocrinologist at Allegheny Health Network’s Center for Diabetes and Endocrine Health, finds fulfillment in helping patients navigate the complexities of diabetes. In this interview, she shares more on how to identify, treat and manage type 2 diabetes.
Catherine Clements: Let’s start with what causes diabetes. Is it preventable?
Dr. Patricia Bononi: Type 1 diabetes is not yet completely preventable, but there is a new medication that can delay the onset of Type 1 diabetes, if identified early enough.
Type 2 diabetes is preventable. If patients are identified at-risk for diabetes, we prescribe lifestyle management programs, like regular exercise or meal plans, to help prevent diabetes. If a patient is overweight, losing 5-7% of their body weight and engaging in aerobic activity 30 minutes a day, 5 days a week will make a significant impact in reducing their risk of diabetes.
Family history, obesity, lack of regular exercise, history of gestational diabetes, and being over the age of 40 increase the risk of diabetes. Some risk factors are modifiable while others like hereditary factors are not. For example, certain ethnic groups, including indigenous people, people of Southeast Asia, African Americans and Hispanics, all have higher risk of diabetes.
Catherine Clements: What are the symptoms of diabetes?
Dr. Patricia Bononi: The classic symptoms are excessive thirst, excessive urination and unexplained weight loss. The concerning thing is that many people with diabetes don't know they have it because symptoms don’t show until much later in the progression of the disease. By the time someone's diagnosed with type 2 diabetes, they've already lost half of their cells that make insulin in the pancreas. That’s why it's important to see your provider regularly and be screened, especially if you have risk factors for diabetes.
Catherine Clements: What does a diabetes screening entail?
Dr. Patricia Bononi: Most screenings occur with your primary care physician and can include a fasting glucose level, or an A1C test, which measures an average glucose over the past three months. Either of these tests diagnose diabetes.
A1C levels should be individualized based on a patient’s age, medications and comorbidities. A healthy range for most people is under 7% without having any low blood sugars.
Catherine Clements: At what point would a patient typically see an endocrinologist?
Dr. Patricia Bononi: Over 90% of patients with diabetes are managed by primary care. Endocrinologists tend to see people with type 1, so those are the patients that need to be on insulin. We also see patients who are struggling to manage their type 2 diabetes. Their A1C may be over 9%, they need to go on insulin, or they have complications. The decision to see an endocrinologist is usually a conversation with their primary care provider.
Catherine Clements: Once diagnosed, what are the treatment options available?
Dr. Patricia Bononi: The mainstay is lifestyle. I encourage people to see a diabetes educator to get a personalized meal and exercise plan. People are sometimes afraid that the dietician is going to prescribe a diet they can’t sustain, but our diabetes educators are great at crafting meal plans that limit, not totally eliminate, carbohydrates. Then, depending on how high someone’s blood sugar is, there are medications to help control glucose.
Catherine Clements: Tell me more about the role of a diabetes educator. When and how do they engage with patients?
Dr. Patricia Bononi: A certified diabetes educator (CDE) is either a nurse or registered dietician that has done additional training to specialize in diabetes. The best time to see a diabetes educator is at time of diagnosis. They’ll help you get on a good meal plan, set your target A1C and create an exercise plan. After that, I recommend patients meet with them annually. Studies have shown that a regular meeting with a diabetes educator lowers A1C — so that's a medication-free way to improve your diabetes management. But if you develop complications, or you have a change in therapy, those are other times you might consider accessing one of our CDEs.
Catherine Clements: Beyond lifestyle changes, what medications are available to manage diabetes?
Dr. Patricia Bononi: Usually, the first line treatment is Metformin to lower glucose. It's safe and has been around a long time. Some of the second line agents that have been getting a lot of attention are the group called the GLP-1 receptor agonists, like Ozempic. With some of the newer medications, the benefits go beyond glucose management — they reduce risks from other diabetes complications. The SGLT2 inhibitors slow the progression of kidney disease, reduce heart failure and lower risk of kidney failure and death in patients with chronic kidney disease and type 2 diabetes.
Catherine Clements: When does it become necessary to take insulin?
Dr. Patricia Bononi: As type 2 diabetes progresses, the pancreas just can’t keep up with the insulin demands. That’s when we’d prescribe insulin. One of the big misconceptions I see is that, if a patient is on insulin, they feel like they failed. This is not true. Needing to take insulin is not the fault of the patient.
Insulin has changed significantly over the years — it’s much easier and much less painful. Almost no one uses vial and syringe. A convenient option for many patients is insulin pens. Then there are insulin pumps that deliver insulin continuously and can adjust your insulin based on where the sensor predicts your blood sugar is going. This takes the work off the patient in terms of delivering the right amount of insulin to regulate their blood sugar.
Catherine Clements: Let’s talk about some of the advances in technology for diabetes management. How are continuous glucose monitors, tracking apps, and other tools impacting patients?
Dr. Patricia Bononi: The continuous glucose monitors have been a game changer. It’s a small device you wear either on your arm or abdomen with a small filament that goes under the skin to measure glucose continuously. The signal either goes to a receiver or the patient’s cell phone — so you can see blood sugar all the time. In the past, people had to stick themselves maybe three or four times a day to get a blood sugar reading and didn’t know their levels in between those readings. I see the continuous glucose monitor almost as an educational tool, because people realize, ‘Oh, when I eat this food, my blood sugar goes up. But when I eat these other foods, my blood sugar stays more stable.’ It's really made a tremendous impact on diabetes management.
Catherine Clements: I had the opportunity to speak with a member using the health plan’s comprehensive diabetes management program who had a really positive experience [see side bar]. Are your patients leveraging this tool?
Dr. Patricia Bononi: Yes, I have some patients who use it and it’s been widely leveraged in primary care. It’s a great resource for day-to-day diabetes management.
Catherine Clements: Why is a coordinated care approach for diabetes so important?
Dr. Patricia Bononi: Diabetes is one of those diseases that requires you to be very proactive. See your provider regularly so that you can catch or prevent complications early.
Collaboration between primary care providers, endocrinologists, cardiologists, nephrologists, diabetes educators, and social workers is key for effective diabetes management. This coordinated approach ensures that all aspects of care are addressed, including medical treatment, lifestyle modifications, mental health, and social services. For example, a patient may need social services to help pay for diabetes medications or support with food insecurity. Additionally dealing with a chronic disease can be very taxing, so many patients need mental health support to manage concerns around diabetes.
Catherine Clements: Do you refer patients to the AHN Healthy Food Center?
Dr. Patricia Bononi: Yes, it’s a tremendous resource we offer. Not only does the Healthy Food Center provide food, but our patients shop with one of the dieticians. So, they learn how to shop for healthy food. I can't say enough about the AHN Healthy Food Center — it’s one of the things I am proudest of at AHN.
Catherine Clements: What gives you hope in helping patients manage their diabetes?
Dr. Patricia Bononi: All the advances in technology and medication make it exciting to go to work every day. The most rewarding thing is the relationships I've been able to develop with some of my patients over time. That gives me hope and spurs me to continue to do this.
Patricia L Bononi, MD, is a specialist in endocrinology and treats patients with diabetes, thyroid disease, osteoporosis, and other endocrine disorders at Allegheny Health Network’s Center for Diabetes and Endocrine Health. She received her medical degree from the University of Pittsburgh School of Medicine. She completed her residency in internal medicine and her fellowship in endocrinology at the University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pennsylvania. Dr. Bononi is certified by the American Board of Internal Medicine for endocrinology and diabetes. She has been recognized as one of Pittsburgh’s Best Doctors, by Pittsburgh Magazine, since 2015.
Hear more from Dr. Bononi in KDKA Radio’s Medical Frontiers.
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