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Ask a Doc: Type 2 Diabetes

In 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 Jamil Alkhaddo, MD, chief, division of endocrinology, AHN.

More than 37 million Americans are living with diabetes, a chronic, progressive disease that is among the nation’s top causes of death. Another 96 million Americans have prediabetes, a serious health condition which often leads to diabetes and can contribute to other health problems as well.

While diabetes always involves problems regulating blood sugar levels, there are different types. Type 1 diabetes occurs because a person’s pancreas doesn’t make the insulin needed 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.

The good news is that nutrition and physical activity can decrease the risk of developing type 2 diabetes. Sometimes aided by medication, diet and exercise can also be effective in helping to manage the disease and limit the damage it causes. However, AHN endocrinologist Jamil Alkhaddo, MD, cautions against oversimplifying type 2 diabetes as merely “a lifestyle disease.” Learn about that and more in our interview below.

“Type 2 diabetes is more than one thing”

Emily Laubham: I’m curious what you think about framing type 2 diabetes as a “lifestyle disease?”

Dr. Jamil Alkhaddo: As they say, for every complex problem, there is one simple, very convincing, wrong answer. The truth is that type 2 diabetes is more than one thing. It is common to describe it as a social and behavioral disease, and your chances of developing type 2 diabetes are much lower if you practice a healthy lifestyle. That’s important — it’s just not the whole story. Genetics and predisposition to diabetes can differ significantly. Someone with multiple family members with diabetes is more likely to develop type 2 diabetes. Some people who do everything “right” still end up with diabetes.

Emily Laubham: Looking at factors that might be in someone’s control, what can we do to lower the chances of developing type 2 diabetes, or help manage it if we’ve been diagnosed?

Dr. Jamil Alkhaddo: Diet, exercise, and taking care of your mental health — that’s the tripod. Those aren’t only for diabetes, they’ll just make your life better.

You can’t separate mind and body. Exercise is so important. I tell my patients, if you had a pill that improved your mental health and decreased your risk of heart disease, diabetes, and stroke, you would take it, right? Well, that’s what regular exercise does. Some people will point out that they are very active at work, or they are running after kids at home, but that is different. When you do half an hour of exercise for yourself, it really pays off.

We all know how many diets are out there promising to solve all your problems. I encourage my patients to focus on something sustainable that they can do long term — make it a lifestyle shift, not just a diet. Keep it simple, too. Maintaining a balance is key. Look at your plate — if carbs are 25% to 30% of what you eat, that’s a good balance. I often ask people what they eat for breakfast, because it tends to be high in carbs.

I’ll add that common comorbidities with type 2 diabetes — hypertension, high cholesterol, and cardiovascular issues — also tend to involve metabolic syndrome. Weight, lack of exercise, and poor diet choices impact all of these conditions.

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A1C testing and glucose monitoring

Emily Laubham: When you have type 2 diabetes, why is regular A1C testing so important?

Dr. Jamil Alkhaddo: To know how your sugars are doing, you can check your numbers regularly during the day with a glucose monitor and you can look at an average number over time, which is the A1C. Most doctors will test patients’ A1C every three months. There is some correlation between A1C levels and the risk of complications for your eyes, kidney, heart, along with other health issues. So, when your doctor tells you, for example, “I want to keep your A1C below 7,” that’s not an arbitrary number.

Emily Laubham: How does the testing approach vary depending on severity — and where does at-home, day-to-day blood glucose testing play a role?

Dr. Jamil Alkhaddo: If your diabetes is in the early stages where we don’t expect to see variations, and you’re on a medication that doesn’t cause significant sugar fluctuations, then you don’t need to check as often. You might not need to check your blood sugar at home as long as you get A1Cs every three months and remain at target.

Unfortunately, the disease is progressive, and it may get worse even when you do the right things. As you get into stages of the disease where you need more medication, or must start taking insulin, then you don’t want to wait three months for A1C tests. You need blood sugar data on a daily basis to help you and your doctor make decisions and adjust treatment. If you’re taking insulin or other medication that puts you at risk of low blood sugar, that becomes another valuable reason to check your blood sugar more often.

Treating and managing type 2 diabetes

Emily Laubham: Can you explain the progression of medication in terms of when it becomes necessary to take insulin?

Dr. Jamil Alkhaddo: Not long ago, we only had two or three classes of medication that we’d try for type 2 diabetes, and if a person’s sugar remained high, we’d add insulin, escalating treatment to get it under control. These days, we have more medication options before we reach the stage of adding insulin, and many of the medications have a very promising impact, not only on diabetes, but on your heart, risk of stroke, and your kidneys.

However, at some point, we may learn that your body just isn’t making enough insulin to control the sugar levels, no matter how many new agents we add. That’s when we would prescribe insulin.

Emily Laubham: Can you talk about how advances in technology, as well as better access to things like glucose monitors and tracking apps, are helping with diabetes management?

Dr. Jamil Alkhaddo: Insulin pumps have been around for a while, and as that technology advanced it took a lot of the work off the patient in terms of delivering the right amount of insulin to regulate their blood sugar.

Over the past few years, there have also been significant advances in what is known as continuous glucose monitoring (CGM) devices. Instead of relying on you to stick your finger to test your blood sugar, these devices have sensors that are inserted under the skin and automatically generate test results at regular intervals. Apps can then help with tracking that data.

These advances have made patients' lives better by giving them peace of mind, and they’ve been shown to decrease A1C levels, hospitalizations, and risk of severe hypoglycemia. With proper support, a patient gets better control and has less burden. This all ties back to the basics of diabetes management: feedback and practice. If you have diabetes and you can see what happens to your blood sugar based on what you just ate or in response to when you took insulin or medication, that’s feedback that you can use to practice and get better at managing the disease.

Emily Laubham: Getting back to medications, can you talk about why someone with diabetes is likely to be prescribed statins for cholesterol? And is there any truth to concerns that statins can contribute to developing diabetes?

Dr. Jamil Alkhaddo: There is a very slight increased risk of progression of prediabetes or diabetes for patients who take statins, but we have to weigh that slight risk against the substantial benefits.

When my patients are hesitant about taking statins, I tell them high cholesterol is similar to diabetes and high blood pressure in that it’s often doing damage silently. You may not feel anything when your cholesterol is high, but it is contributing to a higher risk of heart disease and stroke. If you’re diabetic, your risk of heart disease and stroke is already pretty high. Statins are shown to effectively and significantly reduce the risk of stroke and heart attack. So, any diabetic above the age of 40 (or younger if they have significant cholesterol), we recommend they go on statins.

Remission and realistic improvements

Emily Laubham: You mentioned that diabetes is a progressive disease. If you’re doing all the right things, how much room for improvement is there — is it ever reversible?

Dr. Jamil Alkhaddo: You can’t really cure diabetes, but there is such a thing as diabetes remission. If you’re able to get off all diabetes medication and keep your A1C in a good range for six months or more, we call that diabetes remission.

By the time you get diagnosed with diabetes, you’ve lost 50% of your functional capacity of insulin production. That can’t be reversed. And sometimes you get to the point where you’re just not making enough insulin no matter what and there’s nothing to do other than take insulin.

But in terms of improvement, since you’re only producing a fraction of the insulin, it’s partly about what you can do to lower the demand. Some of the newer medications really reduce your insulin requirements, allowing patients to stop taking additional insulin. If someone loses a significant amount of weight through lifestyle changes or gets gastric bypass surgery, their insulin resistance will drop significantly. If they eliminate or reduce the extra sugar they’re taking into their body on a daily basis, that also means less insulin is needed. So, even if someone isn’t making much insulin, what they are able to do to control the demand is sometimes enough to avoid or get off insulin treatment.

The role of primary care providers and coordinated care

Emily Laubham: How important is a coordinated care approach like AHN’s in helping patients with diabetes, especially those with comorbidities?

Dr. Jamil Alkhaddo: First, our primary care colleagues are a very active part of diabetes care. 90% or more of people with diabetes get their care directly from primary care — it’s rare that they see an endocrinologist. That’s why focusing on delivering the best care at the primary care level is essential, as well as supporting primary care with the support they need to achieve better diabetes control. Many of our practices have been transformed to now include a pharmacist, dietician, even a social services team. You need the collaboration between all these parties to achieve a meaningful impact on diabetes.

Emily Laubham: How does that connect to a paper you co-authored about how reimbursement and operational choices could support coordinated diabetes care?

Dr. Jamil Alkhaddo: When someone comes in to see an endocrinologist at AHN, we use a coordinated care approach — similar to primary care, we have a team, including pharmacists, social workers, and behavioral health workers, who can intervene with patients who need these resources. But an important point is that there is a shortage of endocrinologists in the U.S. We couldn’t manage all the people with diabetes even if we wanted to. The paper reflects our thinking that the best approach is to focus on supporting primary care, including by having endocrinologists build relationships and bridges and through co-managing patients. The primary care world is so much more than just diabetes, obviously, so it’s a question of how we can close any knowledge gaps and provide the right support at the right time.

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