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CartoonMD Questions and Answers:

Q. I want to know if a 5-Star General can have diabetes? Whats up pal?
A. Yes, and baseball players can too!Can't get through to your email. How do I make contact?

Q. Why when someones triglycerides are extremely elevated can't LDL levels be measured?
A.
Thanks for the question. This one is a little more intricate than the average question, but I'll try to make the answer as simple as possible.

It's pretty expensive to directly measure LDL cholesterol levels in the blood, so the LDL cholesterol levels on a person's blood panel is usually calculated off of the following values: total cholesterol value, triglyceride value, HDL cholesterol value.

These values are easier and less expensive to measure.

There's a formula called the Friedewald equation which states:

LDL = TC - HDL - TG/5

That is, the LDL cholesterol level equals total cholesterol minus the HDL cholesterol level minus the triglyceride level divided by 5.

This formula allows the lab to calculated the LDL cholesterol level off of those other, less expensive to obtain numbers.

The only problem is, this formula falls apart and is inaccurate in certain settings. One setting where the formula doesn't work is when the triglyceride levels is above 400.

When that happens, one has to go to the more expensive direct measurement of the LDL cholesterol.

I hope that helps.

Dr. Grady (Dr. Matrisciano)

Q. Dear Dr. Grady, Five months ago, I was diagnosed with Type 2 diabetes. Since then, I have lost 40 pounds(I weigh 168 now) and have been on a 100g carbs a day. The sugar readings both post prandial and fasting are less than 100. Since April, I do not take any medicine. Q. My Cholesterol is 157, Aic = 5, TG = 94, do I need to take statin Drugs? Respectfully submitted, Cyrus
A. Cyrus,

Congratulations, it sounds like you're a model for treating diabetes with weight loss/diet (and maybe exercise too?) Those numbers sound great.

It is difficult to answer for any given individual whether or not they should use a statin drug without treating them directly as a patient, but I can give you an idea what is done in some cases that have similar elements to your case.

First, a clinician will get a fix on what cardiac risk factors a person has - including smoking history, hypertension history, family history of coronary disease, among other risk factors.

In addition, a clinician will see if a person has (or still has) diabetes or impaired glucose tolerance/impaired fasting glucose.

If a person has lost a great deal of weight, this will tend to lower insulin resistance and may even eliminated diabetes and impaired glucose tolerance. This is generally done using updated fasting glucose levels and/or an updated glucose tolerance test.

Based on this information and a breakdown in the lipid numbers (individually seeing the triglyceride, LDL, and then HDL levels), and other medical information about a patient (other medical history, exam, etc.), a clinician will then make a decision on whether the benefits of using a statin outweigh the downsides.

Many endocrinologists would use statin medications for people who have even mild diabetes or impaired glucose tolerance even if the A1c and lipid numbers are all excellent. The reason this is often done is because statins have anti-inflammatory effects in the coronary arteries in addition to their possible benefits on lipid numbers.

You can to to YouTube.com and search under "CartoonMD" to see my video at the drawing board on "Statins in Diabetes" for a review of this.

In the end, however, you must ask your health care provider as to whether or not you should use a statin drug - based on all of the clinical information put together.

Dr. Grady (Dr. Matrisciano)

Q. Dr. Grady, I have been diagnosed with Paget's disease and was wondering what the treatments might be. The documentation says I should be seen by an endochrinologist. Thank you, Mike Vetrano
A. Mike,

Assuming you're talking about Paget's disease of the bone - which is considered a metabolic disease of the bone and is different from Paget's disease of the breast - many people will see an endocrinologist for an evaluation for this. However in different geographic areas of the United States, different specialists may be treating Paget's disease of the bone. In some areas, rheumatologists or other specialists may treat it. But many primary care providers treat it as well. It's best to ask your primary care provider as to the best approach to treating your condition.

Depending upon the specific case, bone X-rays, nuclear bone scans, blood testing, and other tests are often used as part of the workup.

If medications are going to be used to treat a particular case of Paget's disease of the bone, medications in the Fosamax family are often used. These drugs are often used to treat osteoporosis, but then are sometimes used in other conditions as well.

As always, it's best to start with asking your primary care provider as to what direction to go with your own particular case.

Dr. Grady (Dr. Matrisciano)

Q. Is depression and diabetes a lethal combination? What kind of treatments do you suggest?
A. Certainly there is a higher likelihoood of developing depression if you have diabetes. Also people who have diabetes often get frustrated with having diabetes and having to deal with diabetes - especially the younger folks with type 1 diabetes.

And if a person has diabetes, it can make it more difficult to precisely and thoroughly handle all of the day-to-day details of managing diabetes like watching diet and monitoring blood sugars and visiting their health care professional regularly.

So diabetes is associated with an increased risk of depression, and depression can hamper a person's ability to effectively deal with diabetes.

The treatments for depression in people with diabetes are similar to those without diabetes. Most people with depression can most effectively deal with it under the guidance and care of their health care provider and/or mental health professionals.

The good news is that depression and diabetes can both be treated very effectively these days in most cases.

Dr. Grady (Dr. "Mat"-risciano)

Q. Are there any known side effects associated with long term use (4 or more years) of Starlix?
A. I am not aware of any major long-term side effects with the use of nateglinide (Starlix), but that's certainly not to say that there are not long term side effects.

I'm not sure if there are enough long-term studies to show whether or not there are long-term side effects of Starlix.

Dr. Grady (Dr. "Mat"-risciano)

Q. what food can diabetics eat and not eat?
A.

Let me refer you to the answer I gave to a prior question about what a person with diabetes can eat. Hopefully this will answer your question for you.

Dr. Grady (Dr. "Mat"-risciano)

Q. I need a simple chart for foods which I cannot eat.
A.
Let me answer your question by discussing how one should eat when they have diabetes.

First of all, no one eating pattern is right for everyone, and when you have other medical conditions in addition to diabetes (liver problems, Crohn’s disease, kidney problems, food allergies, etc.) your dietary requirements will be different. So everyone with diabetes should consult with a nutritionist to find out what they should be eating given their specific situation.

One of the best websites out there on general nutrition recommendations is MyPyramid.gov. On the site it can plug in their age, sex, and fitness level, and the site will generate a sample meal plan for you. Again, if you have diabetes or any other major medical condition, you should still talk to a nutritionist to see very specifically what’s best for you.

In general, though, here are some pointers on food choices and what to limit in your diet if you have diabetes.

First, for most people with diabetes, there are no foods that you “can never, ever, ever eat again”. Most people with well-controlled diabetes will, from time to time, have some “no-no” foods in moderation. Remember – in moderation. One should try not to think of any foods as being absolutely forbidden. It can make a person obsessed with these “forbidden foods” and then lead to bingeing on those foods. So most people with diabetes can eat just about any food, but some have to be eaten in extreme moderation.

Given this, I can not provide a list of foods that a person with diabetes can not eat, as there is really no such list. But let me point you towards what you’re looking for – a list of foods that you should try to have very little of and very infrequently.

Trans fats should be kept to a minimum. Trans fats increase the risk for coronary heart disease – the main complication of diabetes. Foods like stick margarine, most commercially baked goods (cookies, crackers, doughnuts, etc.), spreadable frostings, and most restaurant fried foods are all in this category. When one references a food label, foods that say “0 grams of trans fat” and do NOT have partially hydrogenated oils in the first 5 ingredients are the best in this regard.

In addition most people with diabetes should try to keep the amount of quickly-absorbed carbohydrates down.

Carbohydrates known as “simple” carbohydrates are made of millions of single sugar molecules. They don’t need much digestion in the intestine before being absorbed, so they rapidly enter the blood stream and are rapidly used up. Simple carbohydrates are found in sugars, milk, fruit, honey, and certain syrups and ceryain food additives (like corn syrup, high fructose corn syrup, and evaporated cane juice).

Any time you eat food with lots of simple carbohydrate, the sugar will get quickly absorbed and can spike the sugar rather high after eating. This can raise your sugar quite a bit. In addition, simple carbohydrates leave your stomach and intestine quickly and can leave you hungry fairly quickly. So keeping the amount of simple carbohydrates down is a good thing. But there are some exceptions here.

Simple carbohydrates taken in the form of milk or fruit are better than those taken in the form of sugar. Why? Because milk and fruit have a good deal of fiber in them, they tend not to spike the sugar up as much as other simple carbohydrate foods.

“Complex” carbohydrates (also known as starches) are carbohydrates that have their sugar molecules attached in molecular chains of single sugar molecules. They take a little more digestion to get absorbed than simple carbohydrates. The foods that contain complex carbohydrates include bread, cereal, beans, rice, pasta, potatoes, etc. The “white”/refined/more processed complex carbohydrates like white bread/pasta/rice should be consumed less as they can spike the sugars more than less processed/higher fiber foods like beans, brown rice, and whole wheat bread/pasta.

Now any time you mix fat and/or protein with carbohydrates to have a “mixed meal”, the fat and/or protein will tend to delay the absorption of the carbohydrates and reduce the sugar spike from those carbohydrates. This is usually the best way to eat carbohydrates when you have diabetes (unless one is having a low sugar episode and wants to get sugar into the system quickly – but that’s another topic).

This discussion only begins to touch on how the foods you eat can play a role in diabetes management. One must go to other sources and a registered dietician to get the best and most updated information available.

(A special thanks on the answer to this question to a good friend and outstanding dietician/clinician – Darcy Clements, RD, CDN)

Dr. Grady (Dr. “Mat”-risciano)

Q. what are normal blood glucose levels
A.
The definition of normal glucose levels may vary from lab to lab, but they are generally about 65 to 140 mg/dL depending upon the time of day and whether or not one has eaten a meal recently.

Also, some labs may use different "units" at the end of the glucose number, and this may result in a very different normal range. We're talking about the standard in the US which is "milligrams per deciliter" or mg/dL for short. Those are the units we are referring to here.

Most labs in US consider a fasting blood sugar below 100 to be normal and sugar two hours after meals or two hours after a glucose drink (as part of a glucose tolerance test)of less than 140 to be normal.

Even those these are the normal numbers if a person does not have diabetes, they may not be the goal/target blood sugars for someone being treated for diabetes. So if you have a question regarding your own sugars, ask your health care provider what your own specific target sugars are.

Dr. Grady (Dr. "Mat"risciano)

Q. what is aldosteronism
A.
If "aldosteronism" refers to "primary hyperaldosteronism", then it's a condition where the adrenal glands are making too much of the hormone aldosterone for no good reason. Aldosterone is a normal and necessary hormone from the kidneys that allows you to hold onto sodium and release potassium. If your adrenals are making too much, you have have high blood pressure and electrolyte abnormalities. Depending upon the precise reason for the primary hyperaldosteronism, the treatment is either medications (spironolactone) or surgery on the adreanls.

Dr. Grady (Dr. "Mat" risciano)

Q. who invented cartoons?
A. The first cave person who drew an image on a wall in a cave

Q. Insulin resistant patient on amaryl and metformin (5'8", 335 lbs). D/Cd amaryl and added januvia. No improvement over several weeks. Restarted amaryl, discontinued januviea, started Lantus 30 units. Experienced spontaneous diarrhea-self discontinued Lantus. Changed metformin to glumetza with no further diarrhea. Poor SMBG (>300mg/dL). Lantus 50 units with gradual increase (one unit/HS). No improvement, added Humalog 5-10 units ac. Flatulation experienced. Can you explain this embarrassing GI event?
A.
It's well known that metformin can cause diarrhea, and the Glumetza brand of metformin may be less likely to cause diarrhea in many people. So if a person has diarrhea from generic metformin and switches to brand name Glumetza, the diarrhea may resolve.

Regarding flatulence and changing insulin, I am not aware of any association between any changes in insulin/addition of another insulin and flatulence.

Of course one diabetes medication that is notorious for causing flatulence is acarbose (Precose). That's why this medication has been difficult to stay on.

Dr. Grady (Dr. "Mat"risciano)

Q. Can you give me an updated list of the medications that contain metformin? I try to keep up on the list for work I have 14 meds currently and need to see if more were added. Thank you
A.

Kristin,

Sorry about the delay in getting this answer out.

I know less than 14 medications that contain metformin. I guess there must be more than these.

The ones I know of and prescribe are...

Metformin HCL generic
Metformin Extended Release generic
Glucophage
Fortamet
Glumetza
Riomet (liquid metformin)
Actoplus Met
Avandamet
Glucovance
Metaglip
Janumet

Dr. Grady (Dr. "Mat"risciano)

Q. Hi If diagnosed w/ hypthyroidism, pcos on metformin500mg bid, levoxyl 50mcg daily, zyrtec 10mg daily and lexapro 20 mg daily and all labs are in range so I am therapeutic is it possible to still be tired enough to sleep 15hrs a day???????????
A.

The treatment of fatigue depends upon what the cause for the fatigue is.

There are many, many medical conditions which can cause fatigue, and not all of these conditions are diagnosed based upon labs.

Some medications can have fatigue as a side effect.

Sticking with diabetes-related causes, if the blood sugars are elevated significantly, this can cause fatigue. The rare, serious side effect of lactic acidosis from metformin can cause fatigue as well.

Some would argue that adjusting the thyroid levels to the “upper end of the normal range” and bringing the TSH level to the lower end of normal may help energy. Some endocrinologists also use the medication Cytomel in addition to levothyroxine (Synthroid) to help reduce fatigue in some people with hypothyroidism.

These are just some of the possibilities, but there are many, many more possibilities as to what can cause fatigue in a given person. Only a full evaluation by a qualified clinician, including taking a good history as to a person’s fatigue, will ever get to the bottom of the cause and treatment of fatigue in a given person.

Dr. Grady (Dr. “Mat” risciano)

Q. I am a type 2 fifty-six year old female who has been using Lantus for about 18 months. My overall control is consistantly good since starting Lantus (A1Cs are 6.0 - 6.2) and I am pleased that my fasting bg levels are usually in the 80s and 90s range. However, every 2-3 months I will get a fasting reading in the 60s, and bg levels stay lower than usual for the rest of the day. I always exercise after dinner, never have a snack between dinner and bedtime, and inject the Lantus at 10:00pm every night. Could this be an error with the way I am injecting when I get the fasting 60s reading?
A.
In the years I have been practicing as a diabetologist, there is one rule that seems to apply to just about everyone with diabetes: no matter how well-controlled or stable a person’s sugars are, there will always be some sugars or patterns of sugars that won’t make sense and you won’t be able to figure out the cause.

Of course there has to be some cause for any set of unexpected or erratic sugars, but the human body has so many variables that affect insulin absorption and effect it can be difficult to figure out what the cause is at times.

Certainly changes in exercise patterns, eating patterns, infections, other illnesses, medications such as steroids, insulin that’s lost some of its effect by being expired or exposed to high/low temperatures, and many, many other variables may throw off a person’s sugars upward or downward unexpectedly.

In addition, even though the different insulin formulations are supposed to have predictable kinetic “curves”, the true curves followed by insulin in the body can actually be fairly variable.

For example, Lantus insulin is supposed to begin to have a good effect in about 4 hours and last 24 hours and have a “flat” profile from hour 4 to hour 24. But this profile can vary from injection to injection and from person to person. And the “flat” curve is not usually perfectly flat. It can rise and fall over the 24 hours. So if a person has fairly tight control of their sugars with Lantus insulin as the basal insulin, simple, normal variations in the kinetics of the Lantus insulin could account for an unexpected action of an insulin from time to time.

So the variations in an insulin’s curve is just one of the many, many possibilities which could explain a variation in the action of a person’s insulin.

Dr. Grady (Dr. Mat[risciano])

Q. Do you have any advice for a 10 year old boy about foot care. He is diabetic.
A. _________________________

I will discuss some general points on diabetes foot care that apply to most people with diabetes. If there is a specific issue going regarding you or someone you know, it’s best to bring that to the attention of his health care provider and/or a podiatrist.

Diabetes-related foot problems can have a number of different causes.

Poor circulation from diabetes can hamper the body’s ability to deliver oxygen and nutrients to the feet. Since the feet are the furthest organs from the heart, they are th organs most prone to having their flow cut off from the body’s main circulation.

Poor circulation can lead to pain, infections, ulcers, and even gangrene in the feet.

Nerve damage from diabetes can hamper one’s ability to feel the pain of foot injuries. This can cause a delay in picking up foot injuries, sores, ulcers, and infections. This delay can cause a delay in treatment and worsen any such injury.

Skin changes such as cracked skin can improve the ability for bacteria to get under the skin and cause infections. Dry skin and fungal infections of the skin can cause cracking.

Problems with the toenails can lead to injuries and infections. Toes that are improperly trimmed may have sharp edges and cause injuries. Injuries can occur during the process of nail cutting. Also, improper nail trimming can lead to ingrown toenails which are painful and can become infected.

If there are any foot deformities, such as bone deformities or bunions, these can cause abnormal and excess pressure and wear and tear on certain parts of a person’s feet and lead to injuries and infections too – especially if you have diabetes.

The foot issues I list above are not meant to be a comprehensive review of all diabetes-related foot problems but some of the highlights. Likewise, I mention some strategies for foot care below, but it’s best to go to your health care provider or another source for a more comprehensive overview on how to care for your feet if you have diabetes.

Some strategies for protecting your feet include:

1) Avoid smoking
2) Avoid walking barefoot
3) Avoid the use of heating pads or warm water bottles on the feet
4) Avoid stepping into a bathtub without checking the temperature first
5) Toenails should be trimmed to the shape of the toe and sharp edges should be filed.
6) Have a podiatrist trim your nails if you can
7) Inspect your feet daily for cracks, injuries, or infections. Use a mirror if needed to get a good look at your feet. Call your health care provider immediately if you see any problems with your feet.
8) Make sure your shoes are snug but not tight, and socks should be cotton, loose fitting, and changed at least daily.
9) If you have any bony deformities or injuries on/in your feet, you should bring this to the attention of a podiatrist who can help guide you in the best type of shoes/socks to use in order to protect your feet. Many people need prescription shoes for best protection.
10) Ask your health care provider to check your feet regularly if they don’t already do so.

Again, these are many strategies that many people with diabetes can use, but not a comprehensive list of strategies and the strategies may not apply to everyone. I recommend you go to other sources to find out more about foot care before proceeding.

Some other sources for information on foot care: Your health care provider, a podiatrist, and books on diabetes and foot care in your local library or at an online or bricks and mortar bookstore.

A direct contact who can give more information on foot care is a wonderful person I’ve known for years who runs the Diabetes Resource Coalition of Long Island, where I’m located. Her name is Susan Wilk, and she can be reached at (631) 727-7850 ext. 385, SRW32@Cornell.edu, or LongIslandDiabetes.org.

- Dr. Grady (Dr. Mat-risciano)

Q. What does GLP-1 in the cartoon stand for?
A.
GLP-1 stands for "glucagon-like peptide 1". Glucagon is a natural hormone the body makes. It comes out of the pancreas. Since the protein GLP-1 is similar in its structure to glucagon, it was given the name GLP-1.

Q. I have a love/hate relationship with my Lantus insulin! I love how it controls my blood sugars ( it's the only med that can control my fasting blood sugars) but hate the fact that it seems to cause weight gain, especially in my abdomen. I am 56 years old, have been a T2 for 3 years, and I'm also on Metformin and Starlix. What exercises/other solutions can help me get rid of the abdominal fat? I currently run 2-3 mi. per day, do 30 crunches per day, and do some free weights.
A.

Let me answer this question in different parts:

First, it may be difficult for a person to find a medication that really controls blood sugars well. If a person finds such a medicine, they should try to stay on it – if medically appropriate as determined by their health care provider.

One big rule of diabetes care is that insulin works. When other medications for type 2 diabetes don’t do the trick, insulin can almost always be used, and it will almost always lower the blood sugars if the right insulin or insulins are given in the right dosage and with the right timing. Lantus, in particular, is known for its ability to provide most people with a smooth, steady insulin delivery for about 24 hours after an injection. Insulin, however, has its down sides. These include the tendency to cause low blood sugars and weight gain.

Definitely diet and exercise are the best attack modes against the tendency for weight gain, and any tendency towards weight gain can be overcome. Unfortunately it is often an uphill battle.

Some physicians will select specific combinations of non-insulin medications along with insulin to minimize weight gain. The “sulfonylurea” medications like Amaryl (glimepiride) and Glucotrol (glipizide), Starlix, and Actos/Avandia can cause weight gain on their own. The medication metformin and Januvia will not cause weight gain. The injectable medication Byetta will tend to push the weight down.

By eliminating medications like Starlix and adding in medications like Januvia or Byetta – if appropriate for that person – some doctors find their patients will have less of a tendency for weight gain.

As far as losing weight specifically in one area…you really can’t lose weight in one specific area. You have to lose weight in general, and the weight in that specific area will disappear along with weight elsewhere. You can only tone up specific areas with specific exercises, but not lose weight in specific areas. One can only lose weight globally.

Dr. Grady (Dr. “Mat”risciano)

Q. How do statins work?
A. Statin drugs are used to lower the risk of heart attacks, strokes, and other forms of cardiovascular disease. They are used in people with diabetes and people without diabetes. People with diabetes, however, are strongly urged to use statin drugs – if appropriate for them – since diabetes puts a person at a 2-3 fold risk for cardiovascular disease.

Statins include the drugs lovastatin (Mevacor), fluvastatin (Lescol), pravastatin (Pravachol), simvastatin (Zocor), atorvastatin(Lipitor), and rosuvastatin (Crestor).

Statins reduce cardiovascular disease in 2 ways:
1) They reduce the level of “bad cholesterol” or LDL cholesterol in the body and thus there is less LDL cholesterol in the circulation to form plaques and blockages in arteries.
2) They have anti-inflammatory effects in plaques which prevents clots from forming on plaques.

Certain cells in the body can create cholesterol. Statins can block the production of cholesterol inside these cells. Since these cells have less cholesterol being produced inside of them, they seek cholesterol from the outside. So the cells will pull cholesterol out of the bloodstream and into themselves. This lowers the level of cholesterol in the bloodstream, and thus lowers the amount of cholesterol available to build plaques inside of arteries.

The sequence that occurs in most heart attacks and many strokes is the following: White blood cells can migrate into plaques that have formed in arteries in the heart or brain. These white blood cells may release enzymes that eat through to the top of the plaque and break through to the bloodsteam. This breakthrough exposes sticky material inside the plaque to the bloodsteam and can trigger the formation of a clot on the plaque. This blocks the blood flow and causes a heart attack or stroke. A plaque with inflammation is considered an “unstable” plaque since it’s prone to this process.

Statins reduce inflammation in plaques and cut down the chances of clots forming on plaques. They can therefore “stabilize” plaques.

Q. I'm 48, have T2D, and I've been taking insulin for the past two years. I exercise once a week and eat right. Is inhaled insulin an option?
A.

Inhaled insulin is an option for many people with type 1 diabetes and type 2 diabetes.

Inhaled insulin is an interesting new delivery system for rapid-acting insulin. “Exubera”, the name for Pfizer’s inhaled insulin, provides a delivery of insulin to the body with a delivery pattern that’s similar to the rapid-acting insulins which include Humalog (lispro), Novolog (aspart), and Apidra (glulisine).

Many people with type 2 diabetes use insulin as a supplement to their therapy when diet and exercise and/or non-insulin medications aren’t doing the trick. Most people taking insulin for type 2 diabetes are either on long-acting insulin as their only type of insulin (e.g. NPH or Lantus or Levemir) or a combination of long-acting and rapid-acting insulin. Many people with type 2 diabetes on insulin are taking pills along with their insulin.

If a person has type 2 diabetes and is on rapid-acting insulin as part of his or her regimen, inhaled insulin might be used as a substitute for the rapid-acting insulin. Inhaled insulin can not be used as a substitute for long-acting insulin. So if a person is on both long-acting insulin and rapid-acting insulin, inhaled insulin can not replace all of her insulin. It can just replace the rapid-acting insulin.

Of course there are some people who can not use inhaled insulin. For example, smokers and those with significant lung disease can not use it. Also, lung testing must be performed before and during the use of inhaled insulin.

Most people taking insulin injections for type 1 diabetes must be on both long-acting as well as rapid-acting insulin in order to control their sugars and prevent the life threatening condition called “diabetic ketoacidosis”. As in type 2 diabetes, inhaled insulin can only replace the rapid-acting insulin and not the long-acting insulin.

Dr. Grady (Dr. "Mat")
Justin Grady Matrisciano MD

Q. WHAT ARE SIGNS AND SYMPTOMS OF DIABETES?
A.

Many people with diabetes or “borderline diabetes” (impaired glucose tolerance [IGT]) don’t know they have diabetes or IGT since mild elevations in blood sugars usually don’t cause any symptoms.

If the sugars are elevated moderately or severely, then one will start having the classic symptoms of diabetes.

These classic symptoms can include fatigue, unexplained weight loss, thirst, frequent urination, nighttime urination, blurry vision, and frequent infections. The early onset of type 1 diabetes can include these symptoms as well as nausea, vomiting, and abdominal pain.

Other signs and symptoms of either type of diabetes could include slow-healing cuts or sores, itching of the skin, changes in vision, chest pain, shortness of breath, numbness and tingling in the hands and feet, erectile dysfunction, and frequent yeast infections. Some of these symptoms can be due to the complications of diabetes such as cardiovascular disease, retinopathy, and diabetic neuropathy.

If a person experiences any of these symptoms, they should seek immediate medical attention.

Dr. Grady (Dr. "Mat")
Justin Grady Matrisciano MD

Q. I don't know the difference between Lantus and symlin, I'm type 1 and insulin resist. Which would work better to controle sugar levels in such cases
A. ___________________________
Lantus insulin and Symlin are two very, very different substances even though they look the same and both are given by injection.

Lantus is a type of insulin. A person with type 1 diabetes will usually die without insulin therapy. A person with type 1 diabetes will not die without Symlin therapy – though Symlin therapy may help stabilize sugars for some people.

In people with type 1 diabetes, Lantus insulin helps replace the insulin that your pancreas is supposed to be making but can’t. Usually insulin replacement is given in two basic forms in people with type 1 diabetes – basal insulin and bolus/meal insulin. Insulin replacement often mimics the way a normal pancreas would provide insulin activity to the body. The body puts out a fairly constant background of insulin 24 hours per day and then puts out extra surges of insulin after you eat. Lantus insulin is an injectable insulin that can be used to mimic the basal/background insulin delivered to the body by a normal pancreas. It is often use in conjunction with rapid-acting insulin before meals.

Symlin is a synthetic replacement for a natural pancreatic protein called amylin. When you have type 1 diabetes, your pancreas can not make insulin. But in addition, it can not make amylin either. Amylin is a protein that normally gets released from the pancreas along with insulin. It helps the insulin push the blood sugars down and it helps smooth out the blood sugars. Some people with type 1 diabetes can benefit from using Symlin under the guidance of an experienced medical professional. It may help lower insulin requirements, stabilize sugars, suppress appetite and lower weight. But not everyone is a candidate for Symlin therapy.

Dr. Grady (Dr. “Mat”)
Justin Grady Matrisciano MD

Q. what organs control your blood sugar levels what hormones are involved?
A.
There are a whole number of different organs and hormones that control your blood sugars, but here are some of the highlights:

Of course the body has organs and hormones that keep the blood sugars down, but the body also has organs and hormones that keep the blood sugar up. The body has these two different things going on since it prefers to keep the sugars within a fairly tight range, and both high blood sugars and low sugars can be bad for the body.

What organs and hormones push the sugar down?

Well the pancreas makes insulin which lowers blood sugars, but other organs are important too.

The liver takes in sugar and stores it. The muscles take in sugar and either store it or burn it off. By taking the sugar in, these organs lower the blood sugar levels.

The pancreas also makes the hormone amylin which helps the liver store sugar, lowers blood sugar levels, and helps the body's blood sugar levels from being erratic.

What organs and hormones push the sugar up?

The pancreas makes a hormone called glucagon which causes the blood sugars to rise. It does so by pushing sugar out of the liver...among other places.

The adrenal glands make adrenaline. This causes the sugars to rise under stress.

The pituitary gland makes growth hormone and the adrenal gland makes cortisol. The steep rise in these hormones in the early morning hours are responsible for the "dawn phenomenon". With the dawn phenomenon, these hormones push sugar out of the liver in the early morning hours and can cause a noticable rise in the early morning sugars, and often make the AM sugars higher than when you went to bed.

Many of these organs and hormones can be seen in action in the cartoons on our web site.

There are probably hundreds more hormones involved in controlling blood sugar levels, but these are some of the highlights.

Thanks for your question.

Dr. Grady (Dr. "Mat")

Q. My mom has diabetes. Will i get it too?
A. We posted an answer to a question that was almost identical to yours a little earlier. Here it is again, though, and thanks for your question.

Dr. Grady (Dr. "Mat" - risciano)
__________________________________

Q. If my mom has diabetes, will I get it? Are there things I can be doing to prevent getting diabetes?

A. Your risk of developing diabetes from a parent depends upon the type of diabetes your parent has – type 2 diabetes or type 1 diabetes.

According to information from the American Diabetes Association, if one of your parents has type 2 diabetes, your risk of getting diabetes is 1 in 7 if your parent was diagnosed before age 50 and 1 in 13 if your parent was diagnosed after age 50.

Even if you’re genetically prone to developing type 2 diabetes, you may not actually develop diabetes. There are definitely things you can do which might help you prevent the development of diabetes. Regular exercise (as long as your health care provider allows you to do so), eating healthy, and keeping your weight down will all lower your chances of developing diabetes. Scientific studies have proven this to be so.

Regular exercise lowers insulin resistance, which means it can not only be used to treat diabetes, but it can also prevent diabetes. Healthy eating which keeps the calories and weight down will also lower insulin resistance. Thus it may also be used to both treat and prevent the onset of type 2 diabetes.

As far as type 1 diabetes goes, if your mother has type 1 diabetes, you have about a 5% percent chance of developing type 1 diabetes over your lifetime. There seem to be environmental factors that trigger type 1 diabetes, but so far we really don’t have a good way to prevent type 1 diabetes from occurring in those who have a genetic risk for developing it.

Dr. Grady

Q. I need a simple chart for foods which I cannot eat.
A.
Let me answer your question by discussing how one should eat when they have diabetes.

First of all, no one eating pattern is right for everyone, and when you have other medical conditions in addition to diabetes (liver problems, Crohn’s disease, kidney problems, food allergies, etc.) your dietary requirements will be different. So everyone with diabetes should consult with a nutritionist to find out what they should be eating given their specific situation.

One of the best websites out there on general nutrition recommendations is MyPyramid.gov. On the site it can plug in their age, sex, and fitness level, and the site will generate a sample meal plan for you. Again, if you have diabetes or any other major medical condition, you should still talk to a nutritionist to see very specifically what’s best for you.

In general, though, here are some pointers on food choices and what to limit in your diet if you have diabetes.

First, for most people with diabetes, there are no foods that you “can never, ever, ever eat again”. Most people with well-controlled diabetes will, from time to time, have some “no-no” foods in moderation. Remember – in moderation. One should try not to think of any foods as being absolutely forbidden. It can make a person obsessed with these “forbidden foods” and then lead to bingeing on those foods. So most people with diabetes can eat just about any food, but some have to be eaten in extreme moderation.

Given this, I can not provide a list of foods that a person with diabetes can not eat, as there is really no such list. But let me point you towards what you’re looking for – a list of foods that you should try to have very little of and very infrequently.

Trans fats should be kept to a minimum. Trans fats increase the risk for coronary heart disease – the main complication of diabetes. Foods like stick margarine, most commercially baked goods (cookies, crackers, doughnuts, etc.), spreadable frostings, and most restaurant fried foods are all in this category. When one references a food label, foods that say “0 grams of trans fat” and do NOT have partially hydrogenated oils in the first 5 ingredients are the best in this regard.

In addition most people with diabetes should try to keep the amount of quickly-absorbed carbohydrates down.

Carbohydrates known as “simple” carbohydrates are made of millions of single sugar molecules. They don’t need much digestion in the intestine before being absorbed, so they rapidly enter the blood stream and are rapidly used up. Simple carbohydrates are found in sugars, milk, fruit, honey, and certain syrups and ceryain food additives (like corn syrup, high fructose corn syrup, and evaporated cane juice).

Any time you eat food with lots of simple carbohydrate, the sugar will get quickly absorbed and can spike the sugar rather high after eating. This can raise your sugar quite a bit. In addition, simple carbohydrates leave your stomach and intestine quickly and can leave you hungry fairly quickly. So keeping the amount of simple carbohydrates down is a good thing. But there are some exceptions here.

Simple carbohydrates taken in the form of milk or fruit are better than those taken in the form of sugar. Why? Because milk and fruit have a good deal of fiber in them, they tend not to spike the sugar up as much as other simple carbohydrate foods.

“Complex” carbohydrates (also known as starches) are carbohydrates that have their sugar molecules attached in molecular chains of single sugar molecules. They take a little more digestion to get absorbed than simple carbohydrates. The foods that contain complex carbohydrates include bread, cereal, beans, rice, pasta, potatoes, etc. The “white”/refined/more processed complex carbohydrates like white bread/pasta/rice should be consumed less as they can spike the sugars more than less processed/higher fiber foods like beans, brown rice, and whole wheat bread/pasta.

Now any time you mix fat and/or protein with carbohydrates to have a “mixed meal”, the fat and/or protein will tend to delay the absorption of the carbohydrates and reduce the sugar spike from those carbohydrates. This is usually the best way to eat carbohydrates when you have diabetes (unless one is having a low sugar episode and wants to get sugar into the system quickly – but that’s another topic).

This discussion only begins to touch on how the foods you eat can play a role in diabetes management. One must go to other sources and a registered dietician to get the best and most updated information available.

(A special thanks on the answer to this question to a good friend and outstanding dietician/clinician – Darcy Clements, RD, CDN)

Dr. Grady (Dr. “Mat”-risciano)

Q. What is the possible impact of an epidural steroid injection on my blood sugars?
A.

Of course the “steroids” we’re talking about here are glucocorticoid type steroids which include medications like Prednisone (prednisolone), cortisone, hydrocortisone, and Decadron (dexamethasone).

When these medications are taken in pill form or as an injection, they will usually raise your blood sugars.

The amount a given glucocorticoid regimen raises your sugars depends upon the strength and dose of the steroid. These steroids often raise the sugars in the mid-day and evening hours and often raise the after-meal sugars in particular. This pattern can occur even if you only take the glucocorticoid tablets in the morning or only in the evening or if you only take a one-time injection. Though this sugar pattern is quite common, steroids can actually raise your sugars at any time of the day.

The effect of the steroid on your sugars often lasts even after the steroid injection or regimen has been discontinued. The effect of the steroid on the sugars may last at least several days. The duration of this effect is also dependent upon the dose and type of glucocorticoid you receive.

All of these patterns may vary from person to person depending upon the nature of his or her diabetes and the nature of the steroid regimen he or she receives. Your health care provider should be able to give you a good sense as to how the prescribed steroid regimen may affect you.

Dr. Grady

Q. I'm a 52yr old type 1 diabetic for 32yrs now who has kept tight control on blood sugars. But for a long time now I either refuse to or can't recognize low blood sugars. I test 10 times a day now & have been testing first by urine then with blood since day one. I've taken about a dozen abulances due to low sugars,& have passed-out I don't know how many times. The past couple years by myself I come-to a few hours after passing out & with some effort manage to help myself. I've cut-up my face & head & knocked teeth out due to mishaps. I can't be liking this. Not being alone now when I come-to & my wife or emergency response are around me I think I'd rather have not come-to! Am I normal,& do I need an endocronologist or a phyciatrist?? Sorry for the long note,& thank-you. Sincerely,Neil Levy
A. Low blood sugars, of course, are one of the trickiest parts of managing diabetes.

Low blood sugars can be quite dangerous. And they’re not just dangerous because of the risk of “lapsing into hypoglycemic shock”, but they can trigger things like car accidents and falls (which can cause dangerous hip fractures).

When a person has frequent lows, the body’s cells actually become used to low sugars and begin to stop recognizing them as low sugars. For example, if you go into the 50s frequently, your body may begin to think a blood sugar in the 50s is normal. Then your body may then stop warning you about sugars in the 50s. Usually you can regain these low sugar feelings after a period of time if you adjust your diabetes regimen and stop having so many low sugar episodes.

If a person with diabetes has neuropathy, the neuropathy may also hamper his or her ability to sense low sugar episodes.

There are basically 2 normal stages of low blood sugar symptoms, adrenaline-like symptoms and then decline in mental function/neurological symptoms. The adrenaline-like symptoms typically occur when your sugars are a little low. They include heart racing, tremors, sweating, anxiety, and hunger. They are your body’s way of telling you to get some sugar in your system quickly. The next level of symptoms are typically signs of sugar that are very low, and they include mental fogginess and other neurological symptoms. Your sugar may be dangerously low when you have these symptoms. If you have frequent low sugar episodes, you may lose the adrenaline

And if you have type 1 diabetes, you’re more prone to having low sugar episodes than if you have type 1 diabetes. Why? Well, people with type 1 diabetes have lost more pancreatic function than those with type 2 diabetes. The pancreas makes hormones other than insulin. It also makes hormones that stabilize the sugars and prevent low sugars. People with type 1 diabetes lose some sugar stabilizing hormones and thus may be more prone to low sugar episodes.

If you have frequent low sugars that are severe causing hospitalization, there are some strategies that endocrinologists may use to help prevent or minimize the risk of low sugars or help you or those around you recover from those episodes more quickly. Various tools that an endocrinologist may use include keeping the sugars less tight, using an insulin pump, changing the type of injections one is using, changing the non-insulin medications one is using, diabetes education sessions, various glucose emergency tablets or gels, and glucagon emergency kits.

An endocrinologist will give you the best chance of managing low sugars well if you’re having many dangerous low sugar episodes.

Dr. Grady

Q. I have many concerns as well as diabetes. I'm interested in asking my doctor about the possibility of substituting byetta for current insulin (my last A1c was 7.3 which is down from initial of 11.0) or asking about combining the amylin and exenalin(sp) to my insulin therapy. I have not been diagnosed but seem to be a candidate for having PCOS (Syndrome O). It's been hard for me to have the energy to exercise and the results have been less than successful. I have HepC (w/ a cirrhotic and "fatty" liver) so that blocks the use of a lot of medications that might help me (as well as clinical trials). How do I go about putting this to my internist so that I can be referred to an endocrinologist with a background in these conditions, and new additional substances that I have never, before coming to this website, heard about? While I don't want to come off as a "know-it-all", I do know a little something about me and my health history that seems to have been ignored in the past due to changing insurance coverage and practitioners. I just want to feel better before I die...
A. While we can’t give you medical advice or specific information about your case/situation in this online format, I think it’s worth mentioning a few of my thoughts about diabetes care here.

Since some of the diabetes medications are fairly new (at the time I’m writing this answer), like Byetta and Symlin, it will usually take the skills and experience of an endocrinologist to help sort out if one is better vs. the other and when medication substitutions can be made. This is especially true when there are other complicating medical issues involved.

In addition, PCOS can be a bit tricky to diagnose and treat, so this may also take the skill and experience of an endocrinologist to diagnose and treat.

Medicine has changed these days and physicians are aware that patients are more informed than they were in the past. Also, patients often need to have a reasonable understanding of their medical condition, often need to ask their doctor questions, and often need to be their own health care advocates in order to receive the best medical care.

Depending upon the type of health insurance a person has, she or he may or may not have to ask their primary care provider for “permission” to see a specialist for insurance purposes. If a person needs such “permission” to see a specialist, they should never be afraid to ask their primary care provider if they can see a specialist. If the primary care provider does not allow a person to see a specialist, but that person still feels that they should see a specialist, one option that person has is to get a second opinion from another primary care provider.

Dr. Grady

Q. How much does stress effect diabetes, and what to do if you can't avoid stress. Stressed out in California
A. Stress can affect diabetes and your blood sugars a great deal. Stress can directly affect your body and the sugars, but it can also indirectly affect your body and your sugars.

First, we’ll go into the direct effect of stress on your body.

Stress can be divided into mental stress and physical stress.

Whenever your body faces a stress, it will go into the classic “fight or flight” mode where your body prepares for some kind of action. Part of this preparation is for your body to release adrenaline and other hormones. These hormones trigger the release of sugar into the bloodstream so your body could use this sugar for energy as you take action against the threat you’re facing.

Unfortunately, when you have type 2 diabetes, your body tends to release too much sugar into the bloodstream and can have trouble getting that sugar back into the cells of the body once the stressor is gone. This leads to higher blood sugars during stress events. Those with type 1 diabetes have sugars that are a bit more unpredictable. They may see their sugars rise, but sometimes their sugars may drop when stress occurs. People with type 1 diabetes have not only lost their ability to make insulin, but they have usually lost their ability to make other sugar-stabilizing hormones. Thus people with type 1 diabetes may be more prone to low sugars, including low sugars during stress events.

The stress events can be mental/emotional or physical. The mental stress around preparing for a big meeting at work, a change in job, a divorce, or other small or large stress event in your life can raise the sugars (raise or lower them in type 1 diabetes). The physical stress of an illness – whether just a common cold or a broken leg – can also affect the sugars in a similar way.

Some mental or physical stressors may affect the sugars and some may not. Sometimes it’s a bit of a mystery as to when the body will show a blood sugar change with a given stressor or not. When people with diabetes have a general pattern of erratic and unpredictable blood sugars, it’s sometimes related to stress. While one can’t generalize and say that all stressors will affect blood sugars, stress in general has a profound affect on diabetes.

How can stress indirectly affect your sugars?

Of course managing one’s diabetes takes a great deal of effort. You usually need to keep a good routine of eating, exercise, blood sugar monitoring, and medication to keep the sugars in line. When a person has a significant emotional stress (a divorce, for example) or physical stress (long recovery from a broken leg), this daily routine often gets thrown off whack. Then the person’s diabetes management can get thrown off whack and lead to worse blood sugar control.

Of course much of the stress we deal with can be unavoidable. Even if you find ways to minimize the stressors in your life, you’ll always have certain stressors in your life that affect your sugars. So what can be done about the effect of unavoidable stress on diabetes?

Relaxation exercises can sometimes help reduce your mental stress leve..

Doing some exercise or extra exercise – as allowed by your doctor - sometimes “burns off” mental stress and lowers insulin resistance in the body. This not only fights off mental stress but directly helps the sugars too by allowing more sugar to move from the blood stream to the body’s cells.

Sometimes you medications may need to be adjusted short-term or long-term during stress events to combat the poor control that can occur.

A great piece on how stress can affect your sugars is on the American Diabetes Association’s web site at www.diabetes.org/type-2-diabetes/stress.jsp.

Dr. Grady

Q. I’m pregnant. Can I pass on diabetes to my unborn child?
A. If you’re pregnant and have diabetes of pregnancy (known as “gestational diabetes”) or type 1 or type 2 diabetes, you must try to keep your sugars under excellent control under the supervision of a health care provider who specializes in diabetes management.

If you have any form of diabetes and have poor sugar control at any time during the pregnancy, certain problems might occur during the pregnancy. Poor control might lead to a very large baby (and thus mechanical problems during delivery of such a large baby), problems with lung maturity/breathing after delivery, and other problems with the baby. However, having diabetes during your pregnancy will not cause the baby to be born with diabetes.

Diabetes in the mother during pregnancy will not cause the baby to be born with diabetes, but the baby may have gotten the genes from you that will put him or her at risk for diabetes over their lifetime. See the earlier question “My mom has diabetes. Will I get it?” for more details on the likelihood of your children developing diabetes over their lifetime.

Dr. Grady

Q. If my mom has diabetes, will I get it? Are there things I can be doing to prevent getting diabetes?
A. Your risk of developing diabetes from a parent depends upon the type of diabetes your parent has – type 2 diabetes or type 1 diabetes.

According to information from the American Diabetes Association, if one of your parents has type 2 diabetes, your risk of getting diabetes is 1 in 7 if your parent was diagnosed before age 50 and 1 in 13 if your parent was diagnosed after age 50.

Even if you’re genetically prone to developing type 2 diabetes, you may not actually develop diabetes. There are definitely things you can do which might help you prevent the development of diabetes. Regular exercise (as long as your health care provider allows you to do so), eating healthy, and keeping your weight down will all lower your chances of developing diabetes. Scientific studies have proven this to be so.

Regular exercise lowers insulin resistance, which means it can not only be used to treat diabetes, but it can also prevent diabetes. Healthy eating which keeps the calories and weight down will also lower insulin resistance. Thus it may also be used to both treat and prevent the onset of type 2 diabetes.

As far as type 1 diabetes goes, if your mother has type 1 diabetes, you have about a 5% percent chance of developing type 1 diabetes over your lifetime. There seem to be environmental factors that trigger type 1 diabetes, but so far we really don’t have a good way to prevent type 1 diabetes from occurring in those who have a genetic risk for developing it.

Dr. Grady

Q. Can I control my diabetes without having to use insulin injections?
A. The answer to this question depends upon whether you have type 1 diabetes or type 2 diabetes and how severe your diabetes is.

If you have type 1 diabetes, you must use insulin in order to live.

Insulin is usually given in the form of injections, but some people with diabetes may be able to replace some of their shots with inhaled insulin now. Another form of insulin delivery that’s available today is an insulin pump. An insulin pump is a device about the size of a beeper that can be worn on your belt. The pump holds a chamber of insulin, and it delivers small amounts of insulin throughout the day under the skin through a tiny hose that is taped to the surface of your abdomen.

If you have type 2 diabetes, you may or may not need to use insulin. If your diabetes is fairly mild, you may be able to control it with diet and exercise alone or diet and exercise with pills (and/or the injectable non-insulin medication called Byetta). If your type 2 diabetes is more severe or difficult to control, there’s a good chance you’ll need insulin injections added into your diabetes regimen.

Dr. Grady

Q. How many people have diabetes? Is it hereditary?
A. Approximately 7% of the population of the United States had diabetes as of 2005. That was 20.8 million people. About 90% of those with diabetes have type 2 diabetes (formerly known as “adult onset diabetes”), while 10% of those with diabetes have type 1 diabetes (formerly known as “juvenile onset diabetes”). The statistics vary among different ethnic groups and in different countries.

The number of people with diabetes in the United States has been increasing over the years as average weight of Americans has gone up. The higher a person’s weight, the more insulin resistance he or she will tend to have – as discussed in our cartoons.

There is a hereditary component to diabetes, but like many medical conditions, having the genes alone will not cause the condition. There must be environmental triggers in addition to the having the diabetes genes in order to develop diabetes. For example, a person may have the genes to develop type 2 diabetes, but she or he may not actually develop diabetes unless their weight is high and/or they lack physical activity.

Even for type 1 diabetes, you must have both the diabetes genes as well as some sort of environmental trigger in order to actually develop diabetes. As an example, if one twin in a set of identical twins (they have identical genes) develops type 1 diabetes, the other twin has only a 50% chance of developing type 1 diabetes – not a 100% chance. This means some sort of environmental factors must be triggering the diabetes in those who have the genes.

Dr. Grady